Can we make an early 'do not resuscitate' decision in severe burn patients?

BACKGROUND: The present study was conducted to examine topic of issuing early do-not-resuscitate (DNR) order at first diagnosis of patients with severe burn injuries in light of current law in Turkey and the medical literature. DNR requires withholding cardiopulmonary resuscitation in event of respiratory or cardiac arrest and allowing natural death to occur. It is frequently enacted for terminal cancer patients and elderly patients with irreversible neurological disorders.

METHODS: Between January 2009 and December 2014, 29 patients (3.44%) with very severe burns were admitted to burn unit. Average total burn surface area (TBSA) was 94.24% (range: 85-100%), and in 10 patients, TBSA was 100%. Additional inhalation burns were present in 26 of the patients (89.65%). All of the patients died, despite every medical intervention. Mean survival was 4.75 days (range: 1-24 days). Total of 17 patients died within 72 hours. Lethal dose 50 (% TBSA at which certain group has 50% chance of survival) rate of our burn center is 62%. Baux indices were used for prognostic evaluation of the patients; mean total Baux score of the patients was 154.13 (range: 117-183).

RESULTS: It is well known that numerous problems may be encountered during triage of severely burned patients in Turkey. These patients are referred to burn centers and are frequently transferred via air ambulance between cities, and even countries. They are intubated and mechanical ventilation is initiated at burn center. Many interventions are performed to treat these patients, such as escharotomy, fasciotomy, tangential or fascial excision, central venous catheterization and tracheostomy, or hemodialysis. Yet despite such interventions, these patients die, typically within 48 to 96 hours. Integrity of the body is often lost as result of aggressive intervention with no real benefit, and there are also economic costs to hospital related to use of materials, bed occupancy, and distribution of workforce. For these reasons, as well as patient comfort, early do-not-resuscitate or do-not-intubate protocol for these patients is suggested. Resources could then be directed to other patients with high expectancy of life and patients with burns that are beyond treatment can experience more comfortable end of life.

CONCLUSION: At present in Turkey, it is not possible to give DNR order for patient with severe burns that are incompatible with survival due to legal interdiction. This subject should be discussed at high-level meetings with participation of doctors, legal experts, economists, and theologians.