title: Early withdrawal of life support in severe burn injury.
abstract: 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 Since mid-2001, all 61 patients who had life support withdrawn were by protocol.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.
authors.affiliation: UW Regional Burn Center, Department of Surgery, University of Washington, Seattle, WA 98104, USA.
authors.forename: Tam N
authors.initials: TN
authors.lastname: Pham
authors.forename: Andrew
authors.initials: A
authors.lastname: Otto
authors.forename: Samantha R
authors.initials: SR
authors.lastname: Young
authors.forename: C Bradley
authors.initials: CB
authors.lastname: Kramer
authors.forename: David M
authors.initials: DM
authors.lastname: Heimbach
authors.forename: Nicole S
authors.initials: NS
authors.lastname: Gibran
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Klein
mesh_terms: D000328:Adult; D000368:Aged; D002053:Burn Units; D002056:Burns / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D002423:Cause of Death; D015331:Cohort Studies; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008020:Life Support Care / Q000592:standards* / Q000639:trends; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D013997:Time Factors; D028761:Withholding Treatment / Q000592:standards* / Q000639:trends; D055815:Young Adult