Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization

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.

What do we know about experiencing end-of-life in burn intensive care units? A scoping review

“…Two studies analyzed 7,020 deaths, finding that multiple organ failure was the most common cause of death among burned patients (Bloemsma et al 2008;Dokter et al 2015). To improve the approach for the critically burned patients' families, other studies evaluated the effect of training and early PC consultation programs applied to multidisciplinary teams from trauma/Burn ICUs and implemented gold standards for comfort care for burn patients (Carmichael et al 2021a(Carmichael et al , 2021bWessman et al 2017;Zack-Williams et al 2021).…”

“…Educational and intervention programs, such as quality improvement initiatives, may help to improve the work of the health-care team, softening the experience of transitioning into the end-of-life spectrum of care for both patients and their families (Carmichael et al 2021a(Carmichael et al , 2021bWessman et al 2017).…”

“…Palliative care PC was rarely involved in end-of-life care in Burn ICUs. Four studies highlighted the input of a PC team, but for a minority of patients (Carmichael et al 2021a(Carmichael et al , 2021bDokter et al 2015;Ismail et al 2011). Qualitative studies with professionals and family members emphasized that PC should come alongside active treatment for severely burned (Bayuo et al 2021a(Bayuo et al , 2021b, focusing on communication, symptom management, and post-bereavement support for relatives and staff (Bayuo et al 2019(Bayuo et al , 2021a(Bayuo et al , 2021b.…”

“…Palliative care Palliative care was rarely involved in end-of-life care provision in burn intensive care units. The input of palliative care was mentioned, but only for a minority of burned patients (Carmichael et al 2021a(Carmichael et al , 2021bDokter et al 2015;Ismail et al 2011).…”

“…Based on this review, it seems that PC is suboptimal in Burn ICUs. Only 4 studies referred to the involvement of PC in end-oflife care provided to a very small number of severely burned dying patients (Carmichael et al 2021a(Carmichael et al , 2021bDokter et al 2015;Ismail et al 2011). Most of these studies were quality improvement initiatives.…”