Palliative Care and Burn Care: Empirically Derived Referral Criteria

Utilisation of palliative/ end-of-life care practice recommendations in the burn intensive care unit of a Ghanaian tertiary healthcare facility: An observational study

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.

Refining the referral criteria of persons who have been burned to palliative care: A modified Delphi approach

A paucity of evidence is available to guide integration of specialist palliative care into burn care. This study's purpose was to develop consensus on referral criteria using a modified Delphi process. Content experts were defined as burn or palliative care providers in locations where the teams have collaborative history; published at least one manuscript or presented nationally on burn and palliative care collaboration; or nomination as having equivalent expertise. N = 202 eligible persons were identified; n = 43 participated in Iteration 1 and Iteration 3 retained 79%. Iteration 1 invited participants to rank published referral criteria on a 9-point Likert-style scale. Consensus was defined as an interquartile range ≤ 2. Consensus items with median scores ≤ 3 were dropped from further consideration. Consensus items with median scores ≥ 7 were considered to be important and excluded in Iteration 2. Iteration 2 which presented non-consensus items with their associated median (interquartile range) and the participant's own ranking from Iteration 1. Iteration 3 presented three models; participants ranked in order of preference and suggested revisions. Consensus was achieved on a final set of criteria for specialist palliative care for persons who sustain burn injuries. Future research should prospectively evaluate the criteria against meaningful outcomes.

Exploring clinicians' decision-making processes about end-of-life care after burns: A qualitative interview study

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.