End of Life in the Pediatric Burn Patient

Challenges in the Management of Large Burns

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.

Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review

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.

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.

Treatment Decisions in Patients with Potentially Non-Survivable Burn Injury in Australia and New Zealand: A Registry-based Study

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).

Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II

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.

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Mortality of burns presented to a burns unit in Africa is about 10%.

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Resources in Africa to manage burn patients are scarce and patients with massive burns may not be offered curative burn care.

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There are no guidelines for palliative care in burn patients.

Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review

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.

The Role of Palliative Care in Burns: A Scoping Review

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.

Predictors of withdrawal of life support after burn injury

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.

Early withdrawal of life support in severe burn injury

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.

End of life decisions and care of the adult burn patient

INTRODUCTION

Despite advancements in the provision of burn care, there is still a significant cohort of patients who fail to respond to therapy or for whom treatment is deemed futile. The decision to withdraw support from, or to implement a Do-Not-Resuscitate (DNAR) order in, such patients can be challenging. Our aims were to review the withdrawal of life-sustaining treatment, issuing of DNAR orders and end of life care in burn patient deaths.

METHODS

A retrospective case notes review was undertaken, for all burn in-patient deaths from 1st April 2001 to 31st December 2007.

RESULTS

Following exclusions, 63 patients were included in our study, with a median age of 56 years (21-94). End of life decisions in younger patients (under 65 years) were more often due to burn severity. In those over 65 years, reasons were due to co-morbidities, and these decisions were made late in the patient's admission. In 34% of patients, end of life care was not comprehensively documented.

CONCLUSION

A coherent, decisive approach should be adopted and adhered to by all members of the multi-disciplinary team, with clear, standardised documentation in place.