102 Early Palliative Care Consultation in the Burn Unit: Increasing Utilization and Areas for Improvement

Abstract

Abstract Introduction Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. While use of PCC is increasing, a prior study showed that less than 2% of patients with major burns had PCC during admission. The purpose of this study is to examine the impact of a protocol using recommended “triggers” for PCC at a single academic burn center. Methods This is a retrospective review of patient deaths over a four-year period (9/2016–8/2020). Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not resuscitate (DNR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended “triggers” for early (< 48 hrs of admission) PCC was instituted in 2019. Triggers included Baux score > 100 and/or complex decisions about treatment including need for cardiopulmonary resuscitation (CPR)/renal replacement therapy (RRT)/vasopressors, or at least two of the following: age > 70, major comorbidities, disagreement amongst family/patient/providers about best course of treatment, or no longer meeting expected milestones. Results 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 Baux score was 112 [IQR 81–133]. Eleven patients (33%) had major comorbidities. Many patients had life-sustaining interventions such as intubation, RRT, or CPR, 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 patients having PCC before death (p=0.004). However, even during the later period, only half of patients had early PCC despite meeting criteria at admission. Conclusions Frequently, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, 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.