End of life decisions and care of the adult burn patient

Ismail, Amir; Long, Jennifer; Moiemen, Naiem; Wilson, Yvonne

doi:10.1016/j.burns.2010.08.009

Cited by 25 publications

(44 citation statements)

References 20 publications

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“…In the few papers that have evaluated reasons for WLS, none evaluated the effect of comorbidities. 5,22 For WLS patients, it is possible that the presence of comorbidities complicated their perceived clinical course, and therefore the decision to withdraw life support.…”

Section: Discussionmentioning

confidence: 99%

“…3 A combination of objective and subjective criteria, including extent and depth of injury, pre-existing medical comorbidities (especially in the older population), clinician knowledge and previous experiences, potential future quality of life, and likelihood to return to independent living are considered. 3,4,5 Patient and family input is important, and necessary, in this decision-making process as the ultimate goal is to act in accordance with patient wishes.…”

Section: Introductionmentioning

confidence: 99%

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Predictors of withdrawal of life support after burn injury

Bartley

Atwell

Cairns

et al. 2019

Burns

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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 < 17 years 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

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Predictors of withdrawal of life support after burn injury

Bartley

Atwell

Cairns

et al. 2019

Burns

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“…They noted that for patients <65years, the decision was most commonly due to %TBSA and burn depth while in the >65-year-old group, comorbidities were the main driver of withdrawal of life support. In the few papers that have evaluated reasons for WLS, none evaluated the effect of comorbidities [5,22]. For WLS patients, it is possible that the presence of comorbidities complicated their perceived clinical course, and therefore the decision to withdraw life support.…”

Section: Discussionmentioning

confidence: 99%

“…The process is often initiated when a patient's injury is deemed non-survivable or when ongoing treatment is deemed futile [3]. A combination of objective and subjective criteria, including extent and depth of injury, pre-existing medical comorbidities (especially in the older population), clinician knowledge and previous experiences, potential future quality of life, and likelihood to return to independent living are considered [3][4][5]. Patient and family input is important, and necessary, in this decision-making process as the ultimate goal is to act in accordance with patient wishes.…”

Section: Introductionmentioning

confidence: 99%

Predictors of Withdrawal of Life Support after Burn Injury

Bartley

Atwell

Charles

2018

Journal of the American College of Surgeons

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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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“…Studies on VCA performed for burns sequels have shed new light on two important concerns in the management of extensively burned patients: the involvement of hands and face, previously considered when defining the limits between intensive care and “futile” therapy , and HLA sensitization . Burned patients are likely to become sensitized due to the risk factors acquired during intensive care; however, as VCA was not an option for these patients previously, no study reported the prevalence, extent, and intensity of this sensitization and the foreseeable difficulties to access to VCA.…”

Section: Introductionmentioning

confidence: 99%

Anti-HLA sensitization in extensively burned patients: extent, associated factors, and reduction in potential access to vascularized composite allotransplantation

et al. 2015

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Summary 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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End of life decisions and care of the adult burn patient

Cited by 25 publications

References 20 publications

Predictors of withdrawal of life support after burn injury

Predictors of withdrawal of life support after burn injury

Predictors of Withdrawal of Life Support after Burn Injury

Anti-HLA sensitization in extensively burned patients: extent, associated factors, and reduction in potential access to vascularized composite allotransplantation

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