Ethical dilemmas in managing severe burns:Is there a place for palliative care?

Introduction: Despite advances in treatment strategies, patients with severe burns rapidly develop complex metabolic changes and multiorgan failure, compromising survival. Severe burns are the ones complicated by major trauma or inspiratory injury, chemical or electrical ones and generally any burns in adults occupying >20% of body surface area, except for superficial burns.

Methods: The presentation of ethical dilemmas in the management of a critically ill burn patient in the emergency department (ED).

Results: A 31-year-old patient was admitted to the ED with 2nd and 3rd degree burns >80% of the total body surface after a tank explosion with hot water and chemicals. Initially presented in full awareness, without wheeze, in hypoxia, hemodynamically unstable with constant unbearable, agonizing pain. A multidisciplinary team consisting of anesthetists, emergency physicians, ENT, intensivist and plastic surgeon was immediately gathered. Some members of the team raised the issue of delayed anesthesia and endotracheal intubation so that the patient could speak to his family who were on the way, as his imminent death was considered almost certain. However, immediate intubation was performed. The patient eventually died 4 hours later in ICU after marked hemodynamic instability and multiorgan failure.

Conclusion: During management of patients with predicted high mortality, immediate decisions are often required to enhance even minimum chances of survival. These decisions often do not consider the real benefit and wishes of the patient at that moment, which raises some ethical dilemmas. Triage of patients for palliative care without transfer to a specialised burn centre is a difficult decision, especially in the absence of both legal framework and a pre-recorded “medical will” of patients, where the goals of care based on their values and wishes are clear.