Medical futility and the burns patient
Burns Unit, Inkosi Albert Luthuli Central Hospital, South Africa. Electronic address: .Burns: journal of the International Society for Burn Injuries (Impact Factor: 1.88). 03/2013; 39(5). DOI: 10.1016/j.burns.2013.02.001
Since its inception in the 1980s 'futility' has been a controversial concept. The history of this concept, its definition and application to burns care are discussed from the perspective of a burn surgeon. Although introduced as an objective (value-free) criterion, futility proves impossible to objectivate and judgements about the value of human life always play a role. The roles of the patient, the doctor, the 'politician' and society at large in futility-decisions are discussed. (C) 2013 Published by Elsevier Ltd and ISBI.
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ABSTRACT: The epidemiology, referral patterns and outcome of patients admitted to a tertiary burns unit in southern Africa were reviewed. The charts of all patients with thermal injury presenting to the Burns Centre at Inkosi Albert Luthuli Central Hospital (IALCH) between 1 January 2008 and 31 December 2010 were reviewed. Information collected included age, gender, past medical history, cause of burn, size of burn, presence of inhalation injury, time before admission, time to excision, length of hospital stay, complications and mortality. Four hundred and sixty two patients were admitted, 296 (58%) children and 193 (42%) adults. The female-male ratio was 1:1.13. The mean total body surface area (TBSA) burned was 12% (interquartile range 8-25%) for children and 18% (interquartile range 10-35%) for adults. Common causes for the burns were in children: hot liquids (71%) and open flame (24%). Major causes in adults were: open fire (68%) and hot liquids (25%). Epilepsy was a contributing factor in 12.7%. Inhalation injury was seen in 13.6% of adults and 14.3% of children with a flame burn. Forty-four percent of referrals from general surgical units were for burns <30% in adults, and 30% for burns <10% in children. More than one in four patients was referred between 1 and 6 weeks post-injury. Overall mortality was 9.1% (5.7% in children and 15.1% in adults). Complications occurred in 21.6% of children and 36.7% in adults, the most common being lung complications such as ARDS and infection, severe sepsis, skin graft failure and contractures. The length of stay was 1 day/% TBSA burn for all burns in children and for burns between 10 and 49% in adults. The epidemiology and outcome of severe burns referred to the Burns Centre at IALCH is similar to those in other units in Africa. The management and referral of burns patients by other hospitals are inappropriate in a significant number of patients.
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ABSTRACT: Introduction Burn victims and their families are faced with an unexpected, life changing injury, and they don’t have the necessary time to adjust to the trauma. Even though there is extensive literature exploring the attitudes of intensive care physicians on forgoing life-sustaining treatment, little is known about end-of-life practices in specialised burn intensive care units (ICUs). The aim of this study was to evaluate physician beliefs, values, considerations and difficulties in end-of-life decisions in burn ICUs. Methods Two hundred and fifty questionnaires were distributed via electronic mail to burn specialists, randomly selected from the directories of the 45th annual meeting of American Burn Association and the 15th European Burns Association Congresses. Results A moral difference between withdrawing and withholding was stated by 73% of physicians, with withholding being viewed as more preferable (42% vs 37%). Primary reasons given by physicians for the decision to withhold/withdraw the treatment were the patient's medical condition/high probability of death (68%), unresponsiveness to therapy (68%), severity of burn (78%) and poor outcome in terms of quality of life (44%). Vasopressors (85%), blood products (68%) and renal replacement therapy (85%) were the common modalities withheld/withdrawn. Almost 50% involved the patients in the end-of-life decisions and 66% involved the family. Conclusions In this first international study on end-of-life attitudes, burn ICU physicians clearly distinguish between withhold and withdrawal decisions, with the majority preferring the former. In contrast to general ICUs, treatment limitation accounts only for the minority of the deaths.
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