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Grossoehme DH, Bish BM, Lou R, Khandelwal A, Brown M, Brown C, Teo E, Friebert S. Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral. J Burn Care Res 2023; 44:1365-1370. [PMID: 36638124 DOI: 10.1093/jbcr/irad005] [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: 11/02/2022] [Indexed: 01/14/2023]
Abstract
Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.
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Affiliation(s)
- Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, 215 West Bowery St, Akron, Ohio, USA
| | - Brianna M Bish
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, 215 West Bowery St, Akron, Ohio, USA
- Kent State University College of Arts and Sciences, 850 University Esplanade, Kent, Ohio , USA
| | - Richard Lou
- Regional Burn Center, Akron Children's Hospital, One Perkins Square, Akron, Ohio, USA
| | - Anjay Khandelwal
- Regional Burn Center, Akron Children's Hospital, One Perkins Square, Akron, Ohio, USA
| | - Miraides Brown
- Rebecca D. Considine Research Institute, Akron Children's Hospital, One Perkins Square, Akron, Ohio, USA
| | - Carrie Brown
- Department of Pediatrics, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, Arkansas, USA
| | - Esther Teo
- Department of Surgery, University of Arkansas for Medical Sciences, 1 Children's Way, Little Rock, Arkansas, USA
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, 215 West Bowery St, Akron Children's Hospital, Akron, Ohio, USA
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2
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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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3
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Grossoehme DH, Shaner V, Friebert S, Brown M, Steiner S, Khandelwal A, Eickmeyer SW, Teo E, Brown C, Lou R. Palliative Care and Burn Care: Empirically Derived Referral Criteria. J Burn Care Res 2023; 44:393-398. [PMID: 35639874 DOI: 10.1093/jbcr/irac073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 11/13/2022]
Abstract
Burns frequently require complex interdisciplinary care. Specialist palliative care (PC) minimizes suffering, aids in decision making, and provides family support in addition to end-of-life care. Specialist PC is a limited resource, best conserved by identifying persons most likely to benefit from a PC referral. Little guidance is available for clinicians on whether and when to refer to PC. This study's purpose was to identify referral criteria using a mixed-methods approach. Data were examined for between-group differences using Fisher's exact, chi-square, or Wilcoxon Rank Sum tests. Qualitative thematic analysis was used to analyze PC provider notes to describe interventions provided. These data formed initial referral criteria, which were reviewed by an expert panel. Significant between-group differences included dying in the burn center; whether multiple patients were transported to the burn center from one event; and ventilator days. Four themes emerged from qualitative analysis. These included managing physical aspects of care; clarifying goals of care; managing end-of-life care; and managing patient/family psychosocial distress. Expert panel input clarified referral criteria language and supplemented the proposed criteria. We present empirically derived referral criteria to guide burn providers in referring persons for specialist PC. Subsequent testing is required to determine their efficacy in improving patient/family outcomes.
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Affiliation(s)
- Daniel H Grossoehme
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Ohio, USA
| | - Valerie Shaner
- College of Public Health, Kent State University, Ohio, USA
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center, Akron Children's Hospital, Ohio, USA
| | - Miraides Brown
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Ohio, USA
| | - Stephanie Steiner
- Paul and Carol David Foundation Burn Institute, Akron Children's Hospital, Ohio, USA
| | - Anjay Khandelwal
- Paul and Carol David Foundation Burn Institute, Akron Children's Hospital, Ohio, USA
| | | | - Esther Teo
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, USA
| | | | - Richard Lou
- Paul and Carol David Foundation Burn Institute, Akron Children's Hospital, Ohio, USA
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Geffre M, Kemp S, Nygaard R, Endorf F, Maiser S. Palliative Care Utilization in Burn Patients. J Palliat Med 2023; 26:106-109. [PMID: 36251844 DOI: 10.1089/jpm.2022.0141] [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: 01/07/2023] Open
Abstract
Background: Burn injuries are a common cause for hospitalization, and severe burns have an increased risk of death in patients with advanced age, inhalational injury, comorbid conditions. Very little is known about the utilization of palliative care consultation in burn patients. Objective: The aim of this study was to evaluate the factors influencing the utilization of inpatient palliative care consultation for patients with severe burn injuries. Methods: This was a retrospective chart review study at a single burn center. Results: Seventeen out of 191 patients (8.9%) received a palliative care consultation with the average time for consultation of 10.3 days. Factors that appear to impact consultation were age, presence of inhalational injury, and multiple comorbid conditions. Conclusion: Inpatient palliative care consultation was underutilized in patients with severe burn injurie. Further research into the outcomes of palliative care consultation could help further support the utility of early involvement in burn patients.
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Affiliation(s)
- Marcus Geffre
- Department of Surgery, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Sarah Kemp
- Department of Surgery, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Rachel Nygaard
- Department of Surgery, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Frederick Endorf
- Department of Surgery, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Samuel Maiser
- Department of Neurology and Palliative Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
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5
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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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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: 0] [Impact Index Per Article: 0] [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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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: 3] [Impact Index Per Article: 1.0] [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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Bayuo J, Bristowe K, Harding R, Agbeko AE, Wong FKY, Agyei FB, Allotey G, Baffour PK, Agbenorku P, Hoyte-Williams PE, Agambire R. "Hanging in a balance": A qualitative study exploring clinicians' experiences of providing care at the end of life in the burn unit. Palliat Med 2021; 35:417-425. [PMID: 33198576 DOI: 10.1177/0269216320972289] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although the culture in burns/critical care units is gradually evolving to support the delivery of palliative/end of life care, how clinicians experience the end of life phase in the burn unit remains minimally explored with a general lack of guidelines to support them. AIM To explore the end of life care experiences of burn care staff and ascertain how their experiences can facilitate the development of clinical guidelines. DESIGN Interpretive-descriptive qualitative approach with a sequential two phased multiple data collection strategies was employed (face to face semi-structured in-depth interviews and follow-up consultative meeting). Thematic analysis was used to analyze the data. SETTING/PARTICIPANTS The study was undertaken in a large teaching hospital in Ghana. Twenty burn care staff who had a minimum of 6 months working experience completed the interviews and 22 practitioners participated in the consultative meeting. RESULTS Experiences of burn care staff are complex with four themes emerging: (1) evaluating injury severity and prognostication, (2) nature of existing system of care, (3) perceived patient needs, and (4) considerations for palliative care in burns. Guidelines in this regard should focus on facilitating communication between the patient and family and staff, holistic symptom management at the end of life, and post-bereavement support for family members and burn care practitioners. CONCLUSIONS The end of life period in the burn unit is poorly defined coupled with prognostic uncertainty. Collaborative model of practice and further training are required to support the integration of palliative care in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Abetifi, Eastern, Ghana.,School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Katherine Bristowe
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, UK
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, UK
| | | | | | - Frank Bediako Agyei
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Abetifi, Eastern, Ghana
| | - Gabriel Allotey
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana
| | - Prince Kyei Baffour
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana
| | - Pius Agbenorku
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | - Paa Ekow Hoyte-Williams
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ashanti, Ghana
| | - Ramatu Agambire
- Department of Nursing, Garden City University College, Kumasi, Ghana
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11
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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: 17] [Impact Index Per Article: 4.3] [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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12
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Cook AC, Langston JA, Jaramillo JD, Edwards KE, Wong HN, Aslakson RA. Opportunities for Palliative Care in Patients With Burn Injury-A Systematic Review. J Pain Symptom Manage 2020; 59:916-931.e1. [PMID: 31775021 DOI: 10.1016/j.jpainsymman.2019.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/19/2022]
Abstract
CONTEXT Patients with significant burn injuries likely have palliative care needs. OBJECTIVES We performed a systematic review of existing evidence concerning the palliative care needs of burn patients. METHODS Through November 26, 2018, we systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using terms representing burn injuries and the eight domains of quality palliative care as outlined by the National Consensus Project for Quality Palliative Care. Eligible articles involved burn-injured patients treated with an intervention targeting at least one of the eight domains. RESULTS Our searches yielded 7532 unique records, which led to 238 articles for full review and 88 studies that met inclusion criteria. Seventy-five studies addressed the domain physical aspects of care and merit a separate systematic review; 13 studies were included in our final review. Four of the seven domains-processes of care, psychologic symptoms, social aspects, and end of life-were addressed by studies but three domains-spiritual, cultural, or ethics-were unaddressed. Included studies highlight potential benefits from peridischarge self-care education programs, peer support, and group therapy in improving quality of life. In patients with severe injuries, end-of-life decision-making protocols were associated with increased utilization of comfort-focused treatments. CONCLUSION Most existing palliative care-related research in burn patients addresses interventions for physical symptoms with minimal literature concerning other domains. Opportunities exist for further research of palliative care in burn populations with emphasis on addressing interventions for all domains and better standardizing the language and outcomes for the palliative care interventions.
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Affiliation(s)
- Allyson C Cook
- Department of Medicine, University of California San Francisco, San Francisco, California, USA.
| | - Jessica A Langston
- Department of Medicine, VA NorCal Health Care System, Sacramento, California, USA
| | | | - Kristin E Edwards
- Department of Medicine-Palliative Care, Bridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut, USA
| | - Hong-Nei Wong
- Lane Medical Library & Knowledge Management Center, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca A Aslakson
- Departments of Medicine & Anesthesiology, Stanford University, Stanford, California, USA
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13
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Cunningham HB, Scielzo SA, Nakonezny PA, Bruns BR, Brasel KJ, Inaba K, Brakenridge SC, Kerby JD, Joseph BA, Mohler MJ, Cuschieri J, Paulk ME, Ekeh AP, Madni TD, Taveras LR, Imran JB, Wolf SE, Phelan HA. Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients. J Burn Care Res 2020; 39:1000-1005. [PMID: 29771351 DOI: 10.1093/jbcr/iry027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.
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Affiliation(s)
- Holly B Cunningham
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Shannon A Scielzo
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Paul A Nakonezny
- Department of Clinical Science and Psychiatry, University of Texas Southwestern, Dallas, TX, USA
| | - Brandon R Bruns
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Karen J Brasel
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health Science University, Portland, OR, USA
| | - Kenji Inaba
- Division of Acute Care Surgery and Critical Care, University of Southern California, Los Angeles, CA, USA
| | | | - Jeffrey D Kerby
- Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bellal A Joseph
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - M J Mohler
- Department of Surgery, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Mary E Paulk
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Akpofure P Ekeh
- Department of Surgery, Wright State University, Dayton, OH, USA
| | - Tarik D Madni
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Luis R Taveras
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Jonathan B Imran
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
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14
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Ribeiro AF, Martins Pereira S, Gomes B, Nunes R. Do patients, families, and healthcare teams benefit from the integration of palliative care in burn intensive care units? Results from a systematic review with narrative synthesis. Palliat Med 2019; 33:1241-1254. [PMID: 31296110 DOI: 10.1177/0269216319862160] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Burn units are intensive care facilities specialized in the treatment of patients with severe burns. As burn injuries have a major impact in physical, psychosocial, and spiritual health, palliative care can be a strengthening component of integrated care. AIM To review and appraise the existing evidence about the integration of palliative care in burn intensive care units with respect to (1) the concept, model and design and (2) the benefits and outcomes of this integration. DESIGN A systematic review was conducted following PRISMA guidelines. Protocol registered with PROSPERO (CRD42018111676). DATA SOURCES Five electronic databases were searched (PubMed/NLM, Web of Science, MEDLINE/TR, Ovid, and CINAHL/EBSCO) until May 2019. A narrative synthesis of the findings was constructed. Hawker et al.'s tool was used for quality appraisal. RESULTS A total of 299 articles were identified, of which five were included for analysis involving a total of 7353 individuals. Findings suggest that there may be benefits from integrating palliative care in burn units, specifically in terms of patients' comfort, decision-making processes, and family care. Multidisciplinary teams may experience lower levels of burden as result of integrating palliative care in burn units. CONCLUSION This review reflects the challenging setting of burn intensive care units. Evidence from these articles suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making process, and family care. Further research is needed to better understand how the integration of palliative care in burn intensive care units may be fostered and to identify the outcomes of this integration.
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Affiliation(s)
| | - Sandra Martins Pereira
- Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,UNESCO Chair in Bioethics, Instituto de Bioética, Universidade Católica Portuguesa, Porto, Portugal.,Centro de Estudos em Gestão e Economia (CEGE), Porto Católica Business School, Universidade Católica Portuguesa, Porto, Portugal
| | - Barbara Gomes
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal.,Cicely Saunders Institute, King's College London, London, UK
| | - Rui Nunes
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,International Network UNESCO Chair in Bioethics
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15
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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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16
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Sheckter CC, Hung KS, Rochlin D, Maan Z, Karanas Y, Curtin C. Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample. Burns 2018; 44:1903-1909. [PMID: 30115531 DOI: 10.1016/j.burns.2018.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population. METHODS All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores. RESULTS 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.
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Affiliation(s)
- Clifford C Sheckter
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States.
| | - Kay S Hung
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States
| | - Danielle Rochlin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University, Stanford, CA, United States
| | - Zeshaan Maan
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States
| | - Yvonne Karanas
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Santa Clara Valley Medical Center-Regional Burn Center, San Jose, CA, United States
| | - Catherine Curtin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, CA, United States; Division of Plastic Surgery, Palo Alto Veterans Affairs, Palo Alto, CA, United States
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