Mohana Karlekar

Utilization and determinants of palliative care in the trauma intensive care unit: Results of a national survey

Background: There is a paucity of data evaluating utilization of palliative care in trauma intensive care units. Aim: We sought to determine current indications and determinants of palliative care consultation in the trauma intensive care units. Design: Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care. Setting/participants: A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma. Results: A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to board-certified palliative care physicians (χ2 = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were “giving up” (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician. Conclusion: Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services.

Care of the critically ill burn patient: An overview from the perspective of optimizing palliative care

&NA; Burn specialists have long recognized the need for and have role modeled a comprehensive approach incorporating relief of distress as part of care during critical illness. More recently, palliative care specialists have become part of the healthcare team in many U.S. hospitals, especially larger academic institutions that are more likely to have designated burn centers. No current literature describes the intersection of palliative care and burn care or integration of primary and specialist palliative care in this unique context. This Perspective gives an overview of burn care; focuses on pain and other symptoms in burn intensive care unit settings; addresses special needs of critically ill burned patients, their families, and clinicians for high‐quality palliative care; and highlights potential benefits of integrating primary and specialist palliative care in burn critical care. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature were searched, and an e‐mail survey was used to obtain information from U.S. Burn Fellowship Program directors about palliative medicine training. The Improving Palliative Care in the Intensive Care Unit Project Advisory Board synthesized published evidence with their own research and clinical experience in preparing this article. Mortality and severe morbidity for critically ill burned patients remains high. American Burn Association guidelines lay the foundation for a robust system of palliative care delivery, embedding palliative care principles and processes in intensive care by burn providers. Understanding basic burn care, challenges for symptom management and communication, and the culture of the particular burn unit, can optimize quality and integration of primary and specialist palliative care in this distinctive setting.

Teaching on the Run: How to Engage Learners from Different Disciplines and Levels of Training on a Busy Palliative Care Service (TH331)

team. The children were not removed from the home and no changes were mandated by CPS. The subsequent care of these children was likely compromised in all three cases. There are significant barriers to reporting the abuse or neglect of dying children. It is difficult for a palliative care team (who may be emotionally attached to a child and family) to assess objectively whether their suspicion of abuse/ neglect is warranted. It is just as difficult for CPS, which may have little experience investigating abuse or neglect of a terminally ill child. The challenge for both teams is to sort out when the line between overwhelming stress and actual neglect/abuse is crossed. As difficult as referral to CPS may be when a child is dying, these children need a voice, and the palliative care team can be that voice.