Elsevier

Injury

Volume 46, Issue 5, May 2015, Pages 870-873
Injury

Clinical differences between major burns patients deemed survivable and non-survivable on admission

https://doi.org/10.1016/j.injury.2015.01.005Get rights and content

Abstract

Introduction

Despite advances in burn care, there is still a group of patients with serious burn injury who fail to respond to therapies or for whom active treatments are unsuccessful. As the demographic and causative factors of burn related mortality may differ between treating units and countries, we aimed to investigate clinical aspects of patients that die whose injuries are considered either survivable or non-survivable on admission.

Methods

A retrospective 11-year medical record review (2000–2011) of patients admitted to the Victorian Adult Burns Service (VABS), Melbourne, Australia, with a fatal burn injury was undertaken. Patient characteristics such as age, gender, total body surface area (TBSA%) burned, type and site of burn, hospital length of stay, receipt of burn care treatments and when withdrawal of care (WOC) took place were identified using hospital databases. For the purposes of categorization, two categories of patients were defined retrospectively. ‘Early WOC’ patients were those for whom a decision was made within the first 24 h following admission that a patient injury was likely non-survivable, or that survival was incompatible with a meaningful quality of life. ‘Late WOC’ patients were those patients for whom a decision was made within the first 24 h following admission that a patient injury was survivable and potentially compatible with a meaningful quality of life.

Results

In a study analyzing 70 patients, the average TBSA% burned in the ‘Early WOC’ group (n = 43) was significantly higher with the ‘Late WOC’ cohort (n = 27) (85% vs. 45%; p = 0.001) compared. A higher incidence of accelerant use (60% vs. 35%; p = 0.07) and facial burns (74% vs. 44%; p = 0.02) was found in the ‘Early WOC’ patients. In the ‘Late WOC’ group, 92.6% of patients required mechanical ventilation and 78.6% of patients underwent operative intervention (median surgical time 9.25 h, inter-quartile range 6.5–18.5).

Conclusion

A number of clinical differences in major burn patients can be observed at admission between patients for whom a decision is made as to whether an injury is survivable or non-survivable. These differences may influence the degree of therapeutic aggression or conservatism as determined by the treating clinical team. As a matter of maintaining standards amongst the burns community, reporting mortality data such as this may also provide a benchmark by which other burns units can assess their own data regarding end-of-life decision-making.

Introduction

Mortality rates for major burns have improved with advances in surgical, critical care and infectious diseases management over the last several decades [1], [2]. As a consequence, more and more patients whose injuries would have been considered untreatable in the past may survive to be discharged from hospital. Clinicians who treat major burns have had to turn their minds towards end-of-life decision making in the context of an increasingly difficult task. They are charged with anticipating whether active and aggressive treatment is likely to result in acceptable outcomes for patients [3]. Although this is a decision made by the clinical team at the time of the patient's admission, often in consultation with the patient and/or the patient's loved ones, the concept of an ‘acceptable outcome’ is a subjective determination that can only truly be made in hindsight by the patient themselves.

Whether the chance of survival of an injury is considered to be zero or negligible is based on the individual opinion of clinicians as determined by their experience and knowledge of mortality-related literature, and is usually informed by projections of the patient's health-related quality of life, likely complications, burden of treatment, patient wishes and family directions [4]. Decisions regarding survivability on admission are made in real-time and as such authoritative and/or administrative bodies such as hospital ethics committees are not involved, nor is it usually practical to involve them.

We present a comparison between deceased patients where care was withdrawn early on in the patients admission (within 24 h) and those who had active treatment but whom care was withdrawn later in the course of their admission. Our aim was to examine the differences between the two groups. Our working hypothesis was that factors such as age, total body surface area burned (TBSA%) and full thickness surface area burned (FTSA%) would be significantly different between the two populations.

We consider that accurate reporting on determining survivability and the timing of death is deficient in the burns literature when it comes to the clinical factors on admission that may help clinicians to determine therapeutic aggressiveness. It must be stated at the outset that rarely are the subjective reasons underlying a clinician's decision to treat or withhold treatment documented in a standardised fashion within medical records amenable to data collection, and to retrospectively assume them for the purposes of a study provides an illusion of clarity that should not be considered reliable. However, reporting on some transparent objective clinical characteristics may provide some guidance for other burn clinicians facing similar difficult decisions regarding survivability of major burns patients on admission as well as reporting mortality data to be used a benchmark by which other burns units can assess their own practice and standards of care.

Section snippets

Setting

The Victorian Adult Burns Service (VABS) is a state-wide adult burns service located at the Alfred Hospital, a 300-bed university affiliated tertiary referral center in Melbourne, within the state of Victoria, Australia. Victoria has a population of approximately 5.55 million people in 2010 with an annual growth rate of 1.9%. The state has a highly organized and centralized trauma system. Approximately 98% of all severely injured adult burn patients in the state are managed at the VABS [5].

Ethics

Results

A total of 3340 persons were admitted to VABS over the 11-year study period for the management of acute burns. We defined a subpopulation of 80 patients who subsequently died. Of these 80 patients, we excluded seven patients because no medical history was available as these cases were greater than 10 years old. In accordance with Australian law, records are not necessarily kept beyond seven years. Three further patients were excluded, of which two had toxic epidermal necrolysis and one suffered

Discussion

Independent predictors of mortality have been extensively studied in major burns patients around the world, often comparing clinical factors of patients who have died against those who have survived [7], [8], [9], [10]. Very few papers however detail those patients that die as an active decision to withdraw treatment, or provide comfort measures alone for patients whom active and aggressive management is likely to be futile or contrary to the patient's best interests. This paper provides a

Conflict of interest

The authors declare no conflict of interest.

Acknowledgements

This project was not funded by any internal or external grant/s.

References (13)

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