Annals of the American Thoracic Society

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.

Approximately 450,000 patients receive medical treatment for burn-related injuries in the United States each year, with about 3,400 deaths being a result of such injuries. Of 40,000 hospital admissions for burns, three-fourths are to burn centers (1), among which half (about 60 centers) meet the requirements of the American Burn Association (ABA; “burn center verification”) (2). Guidelines developed by the ABA with the American College of Surgeons include criteria for referring patients to burn centers, organizational structure, qualifications of medical personnel, and availability of specialists for consultation (3). On average, acute care hospitals—other than burn centers—have fewer than three burn admissions per year.

Recent decades have seen decreasing mortality due to burns (4, 5), which is attributed primarily to advances in overall critical care management and development of specialized burn care teams (6). Still, 25% of patients aged 45–64 years with severe burns die; morbidity remains high for burn injury survivors; and sequelae impair patients’ quality of life for months to years or permanently (7). Care for patients with severe burns is complex and requires a team that attends to the physical, emotional, and spiritual needs of patient, family, and staff.

Specialized burn centers opened in the United States beginning in 1947 (8). Burn care was one of the first surgical specialties to focus on pain management and restoration of function, and it has been described as the most riveting and well-developed paradigm for surgical palliative care (9). Burn specialists helped define the multidimensional nature of pain and the need for a comprehensive interprofessional approach that incorporates relief of distress as part of care for critical illness and injury. Today, an increasing number of hospitals, especially large academic institutions that are more likely to have burn centers, also have palliative care consultation services that can help primary teams in intensive care units (ICUs) and elsewhere to address challenges in management of pain and other symptoms across physical, psychological, and spiritual domains; mutually informed shared decision making; family support; and transition planning (10).

This article addresses unique issues arising in burn unit palliative care. To provide context, we briefly review key aspects of current burn care practice and outcomes of burn injury. We then discuss management of pain and nonpain symptoms in burn critical care settings. Finally, we focus on integration of potential contributions from palliative care specialists with “primary” (i.e., nonspecialist) palliative care by the burn clinical team (11).

During April 2015 and again in Fall 2016, literature searches were performed in the MEDLINE and Cumulative Index to Nursing and Allied Health Literature bibliographic databases using the EBSCOhost platform (EBSCO Information Services, Ipswich, MA). The search results were not restricted by date range but were limited to only English-language articles. A combination of medical subject headings and Cumulative Index to Nursing and Allied Health Literature subjects and keywords were used along with Boolean operators. Some of the search terms used in various combinations were burns, burn units, burn patients, family, family relations, physician’s role, nursing care, burn nursing, critical care, ICU, palliative care, end of life, nurse attitudes, critical care nursing, hospice and palliative nursing, nursing ethics, nurse–patient relations, professional–patient relations, physician–patient relations, professional–family relations, physician–nurse relations, stress, distress, depression, analgesics, opioid analgesics, methadone, nonnarcotic analgesics, conscious sedation, hypnotics and sedatives, hydrotherapy, attitude of health personnel, and burnout. A total of 152 articles were identified and reviewed by three of the coauthors (D.E.R., M.B.K., and D.L.C.), who summarized relevant evidence. We also conducted an e-mail survey of program directors of burn fellowships about palliative medicine training. Our interprofessional and interdisciplinary Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board, comprising representation from medicine, nursing, and social work and including surgical, medical, critical care, palliative care, and pediatric critical care specialists, synthesized the published evidence together with their own research and clinical experience in preparing this Perspective.

Burns are initially assessed for size and depth, with attention to possible smoke inhalation and carbon monoxide or cyanide poisoning. The following criteria warrant consideration for transfer to an ABA burn center: partial thickness burns over greater than 10% of total body surface area (TBSA); full-thickness burn of any size; suspected inhalation injury; serious chemical injury; circumferential partial thickness or full-thickness burns; multiple comorbidities; high-voltage electrical injuries; burns to face, hands, feet, perineum, and major joints; hospitals without qualified personnel; and patients who will require special social, emotional, or rehabilitative interventions (12).

In most ABA burn centers, patients are admitted to a dedicated critical care burn unit where care is delivered by a team of burn surgeons, intensivists, anesthesiologists, nurses, physical therapists, nutritionists, and mental health specialists. Patients typically remain in these units until hospital discharge. For patients with burns on less than 90% of TBSA who die, hospital length of stay is roughly 3 weeks (4). For those patients who survive, length of stay is related to burn size and equivalent to 1 day per 1% TBSA burned (4). Continuity of care in the burn unit helps promote physical, emotional, and psychological recovery of the patient and has a positive effect on the family’s recovery, but it may also contribute to clinician distress (13).

Age, burn surface area, and inhalation injury are the main outcome predictors, but their weighting varies among scoring systems. The Baux score predicts burn injury outcomes as follows: Mortality increases with age and TBSA burned; inhalation injury adds a 10-fold higher risk (4). The addition of non–burn-specific measures (Acute Physiology and Chronic Health Evaluation score, Sequential Organ Failure Assessment score, Simplified Acute Physiology Score, and Pediatric Risk of Mortality score) has not been studied but may improve accuracy (14). Older patients (aged >70 yr) with burns over greater than 40% of TBSA and concurrent inhalation injuries are at particularly high risk of death (1517). Overall, formal scoring systems are more useful for research than for bedside decision making (14).

With decreasing mortality over the past 2 decades, outcome measures for burn injury and care have increasingly been focused on functional status and health-related quality of life (6). “Recovery” to an acceptable quality of life is often more important than simple survival (18). However, meaningful recovery is defined differently by each individual, making such recovery a difficult construct to measure. Less than 30% of adult burn survivors return to work (19).

A major burn represents a tremendous physiologic stress associated with anatomic, physiologic, endocrinologic, and immunologic alterations (20). The postburn hypermetabolic response involves massive protein and lipid catabolism, total body protein loss, muscle wasting, peripheral insulin resistance, increased energy expenditure, and stimulated synthesis of acute-phase proteins (21). This catabolic state can persist for up to 1 year and is associated with impaired wound healing, increased infection rate, tachycardia, loss of lean body mass, slowed rehabilitation, and delayed community reintegration.

Robust randomized controlled trials are lacking for most strategies or treatments in burn care. Recommendations are based on observational data and/or expert opinions, and many remain controversial (22). Timely fluid resuscitation is the cornerstone of acute burn care (23) and has had the greatest influence on patient survival (20, 24). The challenge is to provide enough fluid to maintain perfusion without overload, which can cause pulmonary edema, myocardial edema, conversion of superficial burns into deep burns, need for fasciotomies in unburned limbs, and abdominal compartment syndrome (25). To address hypercatabolism, enteral nutrition is initiated within 6–12 hours (26).

Acute upper airway obstruction occurs in 20 to 33% of hospitalized patients with inhalation injury, and progression from mild pharyngeal edema to complete obstruction can be rapid (27). Care remains supportive. Pneumonia is the most frequent medical complication of burns, especially in patients on mechanical ventilation for over 4 days (12).

Strategies to reduce morbidity include early wound excision and closure, maintenance of body temperature by increasing ambient room temperature, high-carbohydrate and high-protein diet, and early physical therapy. Pharmacologic interventions include recombinant human growth hormone, low-dose insulin infusion, β-blockade, and synthetic testosterone analogue (oxandrolone) (7).

Superficial burns do not typically require surgical excision. Early surgical intervention is recommended for deeper injuries that subsequently require allografting or autografting. Early escharotomy is performed to prevent tissue injury that can worsen edema and pressure, leading to necrosis. Patients with large burns require multiple surgical procedures over weeks to months for staged excision and grafting. These procedures are associated with significant pain, as well as blood loss, hypothermia, and cardiovascular stress (28).

Hydrotherapy has a long history in burn care, initially as the primary treatment modality but now as adjunctive therapy (29). Typically performed with an immersion tank or shower/sprayer, hydrotherapy uses water—with or without antimicrobial solutions—to facilitate dressing changes and debride residual topical agents, wound exudates, and necrotic tissue. Use of hydrotherapy is decreasing because of concern for nosocomial infection, decreased need to remove topical agents, and the associated pain and anxiety (29).

Once wound closure is achieved, patients are transitioned to inpatient rehabilitation. However, some deep wounds may not be amenable to any form of closure, necessitating amputation and long-term morbidity, thus complicating physical and emotional recovery.

Pain is overwhelmingly the most prevalent and distressing symptom for the burn patient and one requiring significant clinical expertise for professional caregivers. Pain varies greatly from patient to patient and can fluctuate tremendously over a hospital course (30). Owing to complex interactions of anatomic and physiologic changes influenced by psychosocial and premorbid behavior issues, burn pain can be highly unpredictable (31). Often, burn pain is severe and persistent. Paradoxically, the intensity of pain is not necessarily directly related to the extent of the burn injury (30).

Damaging only the outer layers of skin, superficial partial thickness burns result in hyperalgesia and mild to moderate pain. Moderate partial thickness burns are associated with marked hyperalgesia, with moderate to severe pain resulting from injury or activation of sensory receptors in the dermis. With deep partial thickness to full-thickness burns, hyperalgesia is typically absent and pain minimal, though patients may describe a deep, aching pain. Pain is experienced at the transition zone between burned and nonburned skin (30).

Burn pain can be characterized in five phases (32). Patients experience background pain resulting from thermal injury and tissue destruction, which is typically low to moderate in intensity and of long duration. This is contrasted with intense pain resulting from procedures such as wound debridement, dressing changes, hydrotherapy, and physical therapy. Unexpected breakthrough pain can occur at rest or during procedures, whereas postoperative pain occurs after burn excision or creation of new and painful wounds resulting from skin harvesting and grafting. Optimal pain control is imperative for wound healing, restorative sleep, participation in activities of daily living, and therapy. Poor pain control has been associated with depression, post-traumatic stress disorder (PTSD), substance abuse, and suicidal ideation (33).

Neuropathic pain after burn injuries is common and occurs throughout the course from acute injury to recovery. It becomes more prominent as the primary cause of pain in the later phase of recovery when the acute burn injury has healed. Symptoms may include burning, stabbing, shooting, or electric sensations (3436). The incidence of localized and peripheral neuropathies ranges from 15 to 37% (7), likely caused by combinations of direct thermal injury, circulating neurotoxins, changes in distribution of fluid and electrolytes, compression by bulky dressings, and stretching of peripheral nerves with improper positioning for prolonged periods. Age, electrical burns, diabetes, and length of ICU stay increase the risk for neuropathies (7).

There is insufficient evidence to support a uniform approach to pain management (37). Because physiologic changes alter pharmacokinetic and pharmacodynamic responses to drugs, treatment of pain can be challenging (38). Thus, traditional approaches to ICU treatment of pain may need to be modified for burn patients, including changes in dosing and dose frequency (31). Dosing and physiologic considerations for opioid analgesics can be found in recent reviews (3941). Nonopioid analgesic considerations are listed in Table 1 (4158). Although pain assessment and management are a fundamental principle and a focus for clinicians in the care of patients with burn injuries, pain is still often inadequately controlled (31). Burn care requires the most rigorous, reliable, consistent, and efficient work processes for assessment and management of pain, with ongoing monitoring of performance and quality.

Table 1. Nonopioid pharmacologic medications in burn care

AgentHalf-LifeDoseUseReference
Ketamine (i.v.)2–3 h0.1–0.5 mg/kg loading dose, then 0.05–0.4 mg/kg/hShort-term analgesia and sedation for proceduresMcGuinness et al., 2011 (42)
Ketamine (p.o.) 5 mg/kgAttenuate hyperalgesia and ineffective opioid analgesiaBarr et al., 2013 (41)
Dexmedetomidine (i.v.)3 h1 μg/kg over 10 min loading dose, then 0.2–0.7 μg/kg/hourShort-term analgesiaLin et al., 2011 (43)
Dexmedetomidine (p.o.) 4 μg/kgSedation for procedures in childrenWalker et al., 2006 (44)
Kundra et al., 2013 (45)
Propofol1.5–31 h5 μg/kg/min initial dose, then titrate by 5–10 μg/kg/min, maximum dose of 80 μg/kg/minDense analgesia/anesthesiaBarrientos-Vega et al., 1997 (46)
Tosun et al., 2008 (47)
Han et al., 2009 (48)
Acetaminophen2 h325–650 mg every 4–6 h, not to exceed 4 g/dNoninflammatory induced mild painRichardson and Mustard, 2009 (49)
Not suitable for treatment of severe burn pain
NSAIDVariableDrug dependentNot suitable for treatment of severe burn painRichardson and Mustard, 2009 (49)
Risperidone20 h0.5–2.0 mg at bedtimeAcute stress symptomsStanovic et al., 2001 (50)
Lorazepam1.5–2 h1–2 mg i.v./p.o. every 2–6 h as neededInsomnia caused by anxietyPatterson et al., 1997 (51)
Generalized anxietyCarrougher et al., 2006 (52)
Severe agitation 
Alcohol withdrawal 
Analgesic effect when combined with opioid 
Gabapentin5–7 h100 mg p.o. three times daily starting dose Titrate up to 5 mg/kg p.o. three times daily; maximum dose 3,600 mg/dPruritusWibbenmeyer et al., 2014 (53)
Not effective in acute painAnand, 2013 (54)
 Goutos et al., 2009 (55)
 Barr et al., 2013 (41)
Pregabalin5.5–6.7 h50 mg p.o. three times daily to start, then increase to 100 mg p.o. three times dailyLate-onset neuropathic painWong and Turner, 2010 (56)
PruritusAhuja and Gupta, 2013 (57)
Lidocaine1.5–2 h1.5 mg/kg loading dose, 1–2 mg/kg/hGeneralized anxietyWasiak et al., 2014 (58)
Analgesia

Definition of abbreviations: i.v. = intravenous; NSAID = nonsteroidal antiinflammatory drug; p.o. = by mouth.

Continuous or long-acting opioids are the standard for treatment, with short-acting opioids used for breakthrough pain (59). Many burn patients develop opioid tolerance, necessitating higher doses than recommended in standard nonburn ICU guidelines. During the acute burn injury, there is increased sensitivity to pain induced by the acute inflammatory response in burned tissue (hyperalgesia). Central nervous system adaptation to prolonged pain or repeated acute pain may amplify the pain experience and result in prolonged hyperalgesia that is unpredictable. Hyperalgesia may also be opioid resistant (30). Slow and careful tapering of opioids during the healing process is essential to preventing drug withdrawal (60). There is little role for acetaminophen and nonsteroidal antiinflammatory medications in the treatment of severe burn pain (49).

Despite opioid medication, most patients being treated for severe burns report severe to excruciating pain during wound care, particularly with hydrotherapy (61). Conscious sedation is frequently used (25). Ketamine or dexmedetomidine can be used for short-term analgesia and sedation during complicated dressing changes (4245), whereas anxiolytics are often used during painful procedures (51, 52). Propofol can be used for mechanically ventilated patients but offers no analgesic effects (4648). Pregabalin has shown some efficacy in treatment of late-phase neuropathic pain (56, 57).

Regional anesthesia is particularly useful for procedures and burn pain relief involving extremities (30). Spinal or epidural opioids can provide background, procedural, and postoperative pain relief. A major drawback to neuraxial anesthesia is the associated risk of meningitis and epidural abscess with insertion through burned skin (30).

Nonpharmacologic techniques such as massage, hypnosis, multimodal distraction, cognitive behavioral techniques, music therapy, and virtual reality games have shown efficacy in reducing pain during wound care (30). Pruritus, neuropathies, anxiety, sleep disturbance, depression, and post-traumatic stress augment perception of pain (7).

Pruritus occurs in up to 70% of patients at 1 year after burn injury and can persist for decades (62, 63). There is no strong empiric evidence on treatment efficacy (64), but multiple treatment options have been described (7, 54). Antihistamines are the mainstay and include topical, oral, and parenteral preparations (55). Gabapentin and pregabalin have shown efficacy for pruritus (54, 55, 57).

Other complications during recovery from burns include hypertrophic scarring, ultraviolet sensitivity and skin pigmentation, and bone and joint changes resulting from disruption of bone metabolism. Musculoskeletal complications include hypertrophic ossification, scoliosis and kyphosis, septic arthritis, subluxations and dislocations of joints (especially in the hands and feet), and amputation (7).

Significant psychological distress is common after major burn injuries and is associated with greater physical and functional impairment (65, 66). The two major psychological issues affecting burn survivors are depression and PTSD. Depression ranges from 4% at discharge, to 54% at 1 month after discharge, to as high as 10 to 20% at 1 year after discharge (6). Rates of PTSD are 6 to 33% at 1 year after injury, similar to survivors of general critical care units, who have a PTSD incidence of 4 to 62% (67).

The emotional morbidity resulting from burn injuries is dependent on age, preexisting psychopathology, economic status, and genetic determinants (6870). Virtually all burn survivors, especially adolescents, have difficulty with body image, self-esteem, mood regulation, cognitive mastery, success in school, and intimate relationships (7). Psychiatric problems such as attention-deficit/hyperactivity disorder, PTSD, phobias, sleep disorders, dementia, autism spectrum disorders, personality disorders, and somatization disorders are common comorbidities in burn patients and often are exacerbated in their recovery (71). Self-inflicted burn injuries, although accounting for less than 1% of all burns, are particularly difficult for patients, families, and staff. The majority of individuals with self-inflicted burns survive, posing complex challenges for treatment and postdischarge rehabilitation. Most of these patients have acted impulsively in the context of psychiatric or alcohol/drug disorders or may have reacted to stressful life events. Survivors can be successfully rehabilitated with early psychiatric and social interventions (72).

Little research has been focused on the impact of a patient’s injury on family, but it is clear that family members can be radically affected after a patient’s burn-related critical illness, which begins suddenly but often continues for a protracted period. Families manifest moderate to severe anxiety and depression after burn injury of a loved one. These symptoms usually abate over the first year (73, 74).

Stressors for those working in a burn center are tremendous. Studies on professional burnout and other forms of clinician distress that were conducted in nonburn ICU settings may also apply to those providers working in burn units (75, 76). Emotional exhaustion, depersonalization, and reduced sense of personal accomplishment can have a marked influence on personal, interpersonal, and organizational performance (77). Moral distress can result in depression, anxiety, emotional withdrawal, frustration, anger, and physical symptoms (78). Although no healthcare professional is immune, most of the experience to date has been reported by nurses (79). Factors including religious beliefs, commitment, and sense of control over the environment modify the personal experience. Patient characteristics may either reduce or intensify these responses (15).

However, the majority of nursing staff in a burn critical care unit do not experience emotional exhaustion or display higher rates of depersonalization than nurses in other ICUs; rather, they perceive higher levels of personal accomplishment (80). Emotional exhaustion is more evident when the nurse believes care is futile or conflicts with the nurse’s values and standards related to the patient’s expected outcome (13). Factors that minimize caregiver stress are interprofessional support and unity, especially regular debriefing sessions and a team culture that encourages use of employee assistance programs (81).

Although primary treatment approaches are similar, pediatric burn patients require special consideration. Diligence in bedside clinical observations, such as mental status, temperature, appearance of extremities, and capillary refill, are imperative in evaluating the efficacy of resuscitation and determining ultimate outcome in the pediatric population (28). Consideration of pain, neurocognitive development, family support, nature of the burn, and anticipated recovery and long-term outcome are major components contributing to pediatric burn care. Importantly, family support influences psychosocial adjustment after burn injury in the pediatric population (82, 83).

Palliative care is an interprofessional subspecialty as well as an approach to care for people facing serious and complex illness, including critically ill and injured patients and their families (84). It is provided along with curative/restorative treatment to relieve basic symptoms, foster effective communication and patient-focused decision making, improve quality of life for both the patient and the patient’s family, and support the primary plan of intensive (and other) care. Another important domain of palliative care in the ICU is support for professional caregivers facing the daily and cumulative challenges of caring for the sickest and most vulnerable patients and their families (85). Integration of palliative care principles and processes is increasingly recognized as a standard of high-quality, comprehensive critical care (86, 87).

Primary palliative care represents the basic competencies required by all clinicians caring for patients with serious and complex illness—skills and knowledge to manage uncomplicated symptoms; discussion of goals of care in relation to the patient’s condition, prognosis, and values; and support of families (11, 88). Specialist palliative care is provided by an interprofessional team of consultants when needs are more complex and/or refractory to primary treatment (88, 89). Palliative care specialists can also help educate, coach, and support clinicians to optimize primary palliative care.

Experts advocate integrated delivery of both primary and specialist palliative care in ICUs and other settings (11, 88). Primary clinicians such as burn critical care teams are committed to and responsible for palliative care delivery, and they have the most continuous and, usually, the most trusted relationship with patients and families. Established national standards for burn care promote a team approach that is patient- and family-centered, emphasizes the importance of continuity of care from injury to recovery, and confirms the competency of burn team members (12). Overall, the interprofessional or interdisciplinary approach by burn clinicians is similar to that of palliative care teams. Primary palliative care is also essential because, despite rapid growth in palliative care consultation programs, there is and will be a significant global workforce shortage of palliative care specialists across professions (90). Current estimates are that 20,000 more such specialists are needed in acute care hospitals, whereas only slightly more than 250 physicians graduate from palliative medicine training programs each year (90). Where available, palliative care specialists have varying levels of specific expertise with burn palliative care, depending on their exposure to and engagement in such care in the course of their consultative work.

At the same time, even burn program academic leaders have recognized deficiencies in palliative care training for burn fellows. In 2015, a survey was sent to directors of the 35 burn fellowship programs (Table 2) in the United States. Most of their institutions have access to a specialty-level palliative medicine consultation service, with many also having palliative medicine fellowship programs. Ninety percent of responding directors endorsed the importance of training for burn fellows in palliative medicine, identifying the following competencies as most relevant: formulation of a prognosis, communication of serious news and disclosure of death, advance care planning, limitation of treatments for which burden exceeds benefit, and management of the imminently dying patient. However, only one-third of the burn fellowship directors reported inclusion of these competencies in their formal curricula. As reported by burn program directors, respondents attributed these gaps primarily to what they perceived as insufficient interest among burn faculty and fellows in palliative medicine education, as well as to inadequate curriculum development in burn surgery.

Table 2. Palliative medicine competencies in burn fellowship training: survey of program directors

 n (%)
Respondents11 of 35 (31%)
Respondents’ institution 
 Has palliative medicine consult service10 of 11 (91%)
 Has palliative medicine fellowship program7 of 11 (64%)
 Burn fellowship led by respondent offers formal training in palliative care competences4 of 11 (36%)
 Training in primary palliative care for burn fellows is important10 of 11 (91%)
Specific competencies felt to be most important 
 Formulation of prognosis10 of 11 (91%)
 Difficult communication, breaking bad news, death disclosure11 of 11 (100%)
 Advance care planning10 of 11 (91%)
 Limitation of nonbeneficial treatments11 of 11 (100%)
 Management of imminent death10 of 11 (91%)
Barriers to palliative care education/training for burn fellows 
 Insufficient interest among burn faculty8 of 11 (73%)
 Insufficient interest among burn fellows6 of 11 (55%)
 Inadequate palliative care curriculum development in burn surgery6 of 11 (55%)

In addition, more than 10,000 burn patients each year are treated in acute care hospitals that are not ABA-verified burn centers (1). In these institutions, intensivists, surgeons, and other clinicians may have less experience, expertise, and/or infrastructure for comprehensive burn care, including palliative care.

In any of these settings, palliative care personnel can help address gaps by collaborating to develop curricula, assist in education and training, and provide other support to ensure delivery of high-quality palliative care (Table 3). This role may be particularly valuable in the context of communication, which presents special challenges. All burn injuries are sudden, and patients’ and families’ ability to process information communicated by clinicians is often seriously compromised (91). Communicating with patients and families has long been identified as an important physician competency. Authors of a literature review conducted by the National Board of Medical Examiners found significant evidence supporting positive associations between physician communication and patient outcomes (92).

Table 3. Potential areas for valuable contributions by palliative care specialists in burn critical care

• Facilitate communication in situations of prognostic uncertainty, complex family dynamics, and death disclosure
• Collaborate in the management of the imminently dying patient
• Provide an extra layer of support directly to burn patients and families in the ICU
• Assist in the training and role modeling of primary palliative medicine skills
• Support palliative care curriculum development for burn critical care education
• Facilitate development of policies or protocols around withdrawal and withholding of nonbeneficial treatments
• Promote resilience and mitigate distress among burn team clinicians

Definition of abbreviation: ICU = intensive care unit.

Until the Milestone Project by the Accreditation Council for Graduate Medical Education (93), however, advanced communication skills training was not required in any surgical specialty. The Accreditation Council for Graduate Medical Education published a communication guide to help inform content for this clinical competency, but it did not provide pedagogical guidance to educators (94). The American College of Surgeons recently recommended creation of education and training programs for surgeons in advance care planning, shared decision-making, and communication skills (95). Palliative care specialists can provide invaluable support for these programs, working with burn teams to develop resources and approaches and to provide training, role modeling, performance feedback, and mentoring. They can also facilitate development of policies or protocols for burn teams and acute care hospitals to optimize end-of-life care, such as comfort care pathways and protocols for limitation of life support. In addition, in burn ICUs as in other critical care settings, specialists in palliative care can provide support for clinicians to promote resilience and mitigate emotional and moral distress and burnout.

When available and appropriate, specialist palliative care teams can also provide an extra layer of support directly to burn patients and families in the ICU. Local culture and expertise currently determine the nature and extent of engagement of these consultants, leading to considerable variation in practice patterns across institutions. To enhance access to palliative care specialists, criteria for referral can be developed in collaboration with the burn team. Such criteria may be modeled on those used in other critical care settings (e.g., need for clarification of goals of care, refractory pain, or other symptoms) (84, 89, 9698) and/or may be framed in terms of factors specific to burn injury, such as Baux score, TBSA burned, comorbidities, or presence of inhalation injuries. Ideally, criteria for specialist engagement will reflect potential contributions by palliative care consultants not simply to care at the end of life but to care meeting a broader range of symptoms, communication, and other needs. In addition, the system of referral should reflect the reality that each patient and family has unique needs and that burn teams have varying levels of primary palliative care knowledge and skill. Ultimately, successful integration of primary and specialist palliative care in the burn ICU will depend on the burn team’s perception of the value of the referral and follow-up on recommendations, which in turn will be influenced by consultants’ responsiveness to and respect for burn clinicians (99). Curiosity and receptivity on the part of palliative care specialists for education and experience in the unique challenges of burn care will also be important. The goal is to support burn teams to provide high-quality primary palliative care while ensuring access to specialist palliative care for patients and families when needed and promoting resilience and professional gratification among burn providers. This combined model can improve ICU palliative care and reduce use of resources without increasing mortality (88, 100104).

Although advances in burn care have driven down mortality (4), morbidity resulting from burn injury with prolonged hospital stays remains high. ABA guidelines (3) have laid the foundation for a robust system that embeds palliative care principles and processes in burn intensive care by primary providers. Working with burn teams, palliative care specialists can enhance this primary palliative care and meet more complex needs of patients, families, and even burn clinicians themselves. Understanding basic care for burn injuries, special challenges of symptom management and communication in burn care, and the culture of the particular burn unit can optimize the value of palliative care consultation in the unique environment of complex burn care. Future research should specifically investigate palliative care needs of patients and families in burn units, as well as the impact of primary and specialist palliative care on outcomes of importance to burn patients, their families, and providers (105).

The authors gratefully acknowledge the contributions of Jacqueline Grove in manuscript editing and preparation and of Jennifer Allen, M.D., in survey development, distribution, and analysis.

1 . American Burn Association. Burn incidence and treatment in the United States: 2016 [2016 Dec 10]. Available from: http://www.ameriburn.org/resources_factsheet.php
2 . American Burn Association. Burn center verification [revised 2015 May; accessed 2016 Dec 10]. Available from: http://www.ameriburn.org/verification_verifiedcenters.php
3 . American Burn Association. Guidelines for the operation of burn centers. In: Resources for optimal care of the injured patient. Chicago: Author; 2006. pp. 7986 [accessed 2016 Dec 10]. Available from: http://www.ameriburn.org/Chapter14.pdf
4 . Bessey PQ, Phillips BD, Lentz CW, Edelman LS, Faraklas I, Finocchiaro MA, Kemalyan NA, Klein MB, Miller SF, Mosier MJ, et al. Synopsis of the 2013 annual report of the national burn repository. J Burn Care Res 2014;35(Suppl 2):S218S234.
5 . Tompkins RG. Survival from burns in the new millennium: 70 years’ experience from a single institution. Ann Surg 2015;261:263268.
6 . Palmieri TL, Przkora R, Meyer WJ III, Carrougher GJ. Measuring burn injury outcomes. Surg Clin North Am 2014;94:909916.
7 . Stoddard FJ Jr, Ryan CM, Schneider JC. Physical and psychiatric recovery from burns. Psychiatr Clin North Am 2015;38:105120.
8 . Brigham PA, Dimick AR. The evolution of burn care facilities in the United States. J Burn Care Res 2008;29:248256.
9 . Dunn GP. Restoring palliative care as a surgical tradition. Bull Am Coll Surg 2004;89:2329.
10 . Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med 2016;19:815.
11 . Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013;368:11731175.
12 . American Burn Association. 2012 National Burn Repository: report of data from 2002–2011. Dataset version 8.0. Chicago: Author; 2012 [accessed 2016 Dec 10]. Available from: http://ameriburn.org/2012NBRAnnualReport.pdf
13 . Rafii F, Oskouie F, Nikravesh M. Caring behaviors of burn nurses and the related factors. Burns 2007;33:299305.
14 . Sheppard NN, Hemington-Gorse S, Shelley OP, Philp B, Dziewulski P. Prognostic scoring systems in burns: a review. Burns 2011;37:12881295.
15 . Taylor S, Jeng J, Saffle JR, Sen S, Greenhalgh DG, Palmieri TL. Redefining the outcomes to resources ratio for burn patient triage in a mass casualty. J Burn Care Res 2014;35:4145.
16 . Atiyat B, Kloub A, Abu-Ali H, Massad I. Clinical sense in the prediction of surgical/trauma intensive care mortality. Eur J Sci Res 2009;30:265271.
17 . Marks RJ, Simons RS, Blizzard RA, Browne DR. Predicting outcome in intensive therapy units—a comparison of Apache II with subjective assessments. Intensive Care Med 1991;17:159163.
18 . Lilley EJ, Bader AM, Cooper Z. A values-based conceptual framework for surgical appropriateness: an illustrative case report. Ann Palliat Med 2015;4:5457.
19 . Mason ST, Esselman P, Fraser R, Schomer K, Truitt A, Johnson K. Return to work after burn injury: a systematic review. J Burn Care Res 2012;33:101109.
20 . Fagan SP, Bilodeau ML, Goverman J. Burn intensive care. Surg Clin North Am 2014;94:765779.
21 . Atiyeh BS, Gunn SW, Dibo SA. Metabolic implications of severe burn injuries and their management: a systematic review of the literature. World J Surg 2008;32:18571869.
22 . Legrand M, Guttormsen AB, Berger MM. Ten tips for managing critically ill burn patients: follow the RASTAFARI! Intensive Care Med 2015;41:11071109.
23 . Pham TN, Cancio LC, Gibran NS; American Burn Association. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res 2008;29:257266.
24 . Barrow RE, Jeschke MG, Herndon DN. Early fluid resuscitation improves outcomes in severely burned children. Resuscitation 2000;45:9196.
25 . Latenser BA. Critical care of the burn patient: the first 48 hours. Crit Care Med 2009;37:28192826.
26 . Hall KL, Shahrokhi S, Jeschke MG. Enteral nutrition support in burn care: a review of current recommendations as instituted in the Ross Tilley Burn Centre. Nutrients 2012;4:15541565.
27 . Mlcak RP, Suman OE, Herndon DN. Respiratory management of inhalation injury. Burns 2007;33:213.
28 . Warden GD. Fluid resuscitation and early management. In: Herndon DN. Total burn care. 4th ed. Philadelphia: Saunders Elsevier; 2012. pp. 115124.
29 . Davison PG, Loiselle FB, Nickerson D. Survey on current hydrotherapy use among North American burn centers. J Burn Care Res 2010;31:393399.
30 . Weichman S, Sharar SR. Burn pain: principles of pharmacologic and nonpharmacologic management. UpToDate [accessed 2016 Dec 10]. Available from: http://www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?source=search_result&search=Burn+pain&selectedTitle=1%7E150
31 . Retrouvey H, Shahrokhi S. Pain and the thermally injured patient-a review of current therapies. J Burn Care Res 2015;36:315323.
32 . Sharar SR, Patterson DR. Burn pain. In: Fishman SM, Ballantyne JC, Rathmell JP, editors. Bonica’s management of pain. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. pp. 755766.
33 . Wibbenmeyer L, Sevier A, Liao J, Williams I, Latenser B, Lewis R II, Kealey P, Rosenquist R. Evaluation of the usefulness of two established pain assessment tools in a burn population. J Burn Care Res 2011;32:5260.
34 . Choinière M, Melzack R, Papillon J. Pain and paresthesia in patients with healed burns: an exploratory study. J Pain Symptom Manage 1991;6:437444.
35 . Malenfant A, Forget R, Papillon J, Amsel R, Frigon JY, Choinière M. Prevalence and characteristics of chronic sensory problems in burn patients. Pain 1996;67:493500.
36 . Schneider JC, Harris NL, El Shami A, Sheridan RL, Schulz JT III, Bilodeau ML, Ryan CM. A descriptive review of neuropathic-like pain after burn injury. J Burn Care Res 2006;27:524528.
37 . Burn pain: a unique challenge. Pain Clin Updates 2001;IX(1).
38 . Woodson LC, Serwood ER, Aarsland A, Talon M, Kinsky MP, Movant EM. Anesthesia for burned patients. In: Herndon DN, editor. Total burn care. 4th ed. Philadelphia: Saunders Elsevier; 2012. pp. 173198.
39 . Joffe AM, Hallman M, Gélinas C, Herr DL, Puntillo K. Evaluation and treatment of pain in critically ill adults. Semin Respir Crit Care Med 2013;34:189200.
40 . Erstad BL, Puntillo K, Gilbert HC, Grap MJ, Li D, Medina J, Mularski RA, Pasero C, Varkey B, Sessler CN. Pain management principles in the critically ill. Chest 2009;135:10751086.
41 . Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, et al.; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263306.
42 . McGuinness SK, Wasiak J, Cleland H, Symons J, Hogan L, Hucker T, Mahar PD. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med 2011;12:15511558.
43 . Lin H, Faraklas I, Sampson C, Saffle JR, Cochran A. Use of dexmedetomidine for sedation in critically ill mechanically ventilated pediatric burn patients. J Burn Care Res 2011;32:98103.
44 . Walker J, Maccallum M, Fischer C, Kopcha R, Saylors R, McCall J. Sedation using dexmedetomidine in pediatric burn patients. J Burn Care Res 2006;27:206210.
45 . Kundra P, Velayudhan S, Krishnamachari S, Gupta SL. Oral ketamine and dexmedetomidine in adults’ burns wound dressing—a randomized double blind cross over study. Burns 2013;39:11501156.
46 . Barrientos-Vega R, Mar Sánchez-Soria M, Morales-García C, Robas-Gómez A, Cuena-Boy R, Ayensa-Rincon A. Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs. Crit Care Med 1997;25:3340.
47 . Tosun Z, Esmaoglu A, Coruh A. Propofol-ketamine vs propofol-fentanyl combinations for deep sedation and analgesia in pediatric patients undergoing burn dressing changes. Paediatr Anaesth 2008;18:4347.
48 . Han TH, Greenblatt DJ, Martyn JA. Propofol clearance and volume of distribution are increased in patients with major burns. J Clin Pharmacol 2009;49:768772.
49 . Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009;35:921936.
50 . Stanovic JK, James KA, Vandevere CA. The effectiveness of risperidone on acute stress symptoms in adult burn patients: a preliminary retrospective pilot study. J Burn Care Rehabil 2001;22:210213.
51 . Patterson DR, Ptacek JT, Carrougher GJ, Sharar SR. Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain 1997;72:367374.
52 . Carrougher GJ, Ptacek JT, Honari S, Schmidt AE, Tininenko JR, Gibran NS, Patterson DR. Self-reports of anxiety in burn-injured hospitalized adults during routine wound care. J Burn Care Res 2006;27:676681.
53 . Wibbenmeyer L, Eid A, Liao J, Heard J, Horsfield A, Kral L, Kealey P, Rosenquist R. Gabapentin is ineffective as an analgesic adjunct in the immediate postburn period. J Burn Care Res 2014;35:136142.
54 . Anand S. Gabapentin for pruritus in palliative care. Am J Hosp Palliat Care 2013;30:192196.
55 . Goutos I, Dziewulski P, Richardson PM. Pruritus in burns: review article. J Burn Care Res 2009;30:221228.
56 . Wong L, Turner L. Treatment of post-burn neuropathic pain: evaluation of pregabalin. Burns 2010;36:769772.
57 . Ahuja RB, Gupta GK. A four arm, double blind, randomized and placebo controlled study of pregabalin in the management of post-burn pruritus. Burns 2013;39:2429.
58 . Wasiak J, Mahar PD, McGuinness SK, Spinks A, Danilla S, Cleland H, Tan HB. Intravenous lidocaine for the treatment of background or procedural burn pain. Cochrane Database Syst Rev 2014;10:CD005622.
59 . Finn J, Wright J, Fong J, Mackenzie E, Wood F, Leslie G, Gelavis A. A randomised crossover trial of patient controlled intranasal fentanyl and oral morphine for procedural wound care in adult patients with burns. Burns 2004;30:262268.
60 . Brown C, Albrecht R, Pettit H, McFadden T, Schermer C. Opioid and benzodiazepine withdrawal syndrome in adult burn patients. Am Surg 2000;66:367370, discussion 370–371.
61 . Carrougher GJ, Ptacek JT, Sharar SR, Wiechman S, Honari S, Patterson DR, Heimbach DM. Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients. J Burn Care Rehabil 2003;24:18.
62 . Willebrand M, Andersson G, Ekselius L. Prediction of psychological health after an accidental burn. J Trauma 2004;57:367374.
63 . Van Loey NE, Bremer M, Faber AW, Middelkoop E, Nieuwenhuis MK. Itching following burns: epidemiology and predictors. Br J Dermatol 2008;158:95100.
64 . Bell PL, Gabriel V. Evidence based review for the treatment of post-burn pruritus. J Burn Care Res 2009;30:5561.
65 . Fauerbach JA, Lezotte D, Hills RA, Cromes GF, Kowalske K, de Lateur BJ, Goodwin CW, Blakeney P, Herndon DN, Wiechman SA, et al. Burden of burn: a norm-based inquiry into the influence of burn size and distress on recovery of physical and psychosocial function. J Burn Care Rehabil 2005;26:2132.
66 . Fauerbach JA, McKibben J, Bienvenu OJ, Magyar-Russell G, Smith MT, Holavanahalli R, Patterson DR, Wiechman SA, Blakeney P, Lezotte D. Psychological distress after major burn injury. Psychosom Med 2007;69:473482.
67 . Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bienvenu OJ, Needham DM. Posttraumatic stress disorder in critical illness survivors: a metaanalysis. Crit Care Med 2015;43:11211129.
68 . Wisely JA, Wilson E, Duncan RT, Tarrier N. Pre-existing psychiatric disorders, psychological reactions to stress and the recovery of burn survivors. Burns 2010;36:183191.
69 . Willebrand M, Low A, Dyster-Aas J, Kildal M, Andersson G, Ekselius L, Gerdin B. Pruritus, personality traits and coping in long-term follow-up of burn-injured patients. Acta Derm Venereol 2004;84:375380.
70 . Andrews RM, Browne AL, Drummond PD, Wood FM. The impact of personality and coping on the development of depressive symptoms in adult burns survivors. Burns 2010;36:2937.
71 . Stoddard FJ, Levine JB, Lund K. Burn injuries. In: Blumenfield M, Strain J, editors. Psychosomatic medicine. Baltimore: Lippincott Williams & Wilkins; 2006. pp. 309336.
72 . Hahn AP, Jochai D, Caufield-Noll CP, Hunt CA, Allen LE, Rios R, Cordts GA. Self-inflicted burns: a systematic review of the literature. J Burn Care Res 2014;35:102119.
73 . Bäckström J, Ekselius L, Gerdin B, Willebrand M. Prediction of psychological symptoms in family members of patients with burns 1 year after injury. J Adv Nurs 2013;69:384393.
74 . Bäckström J, Oster C, Gerdin B, Ekselius L, Willebrand M. Health-related quality of life in family members of patients with burns. J Burn Care Res 2014;35:243250.
75 . Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007;175:686692.
76 . Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, Chevret S, Schlemmer B, Azoulay E. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 2007;175:698704.
77 . McCarthy P. Burnout in psychiatric nursing. J Adv Nurs 1985;10:305310.
78 . Leggett JM, Wasson K, Sinacore JM, Gamelli RL. A pilot study examining moral distress in nurses working in one United States burn center. J Burn Care Res 2013;34:521528.
79 . von Baeyer C, Krause L. Effectiveness of stress management training for nurses working in a burn treatment unit. Int J Psychiatry Med 1983-1984;13:113126.
80 . Murji A, Gomez M, Knighton J, Fish JS. Emotional implications of working in a burn unit. J Burn Care Res 2006;27:813.
81 . Kornhaber RA, Wilson A. Psychosocial needs of burns nurses: a descriptive phenomenological inquiry. J Burn Care Res 2011;32:286293.
82 . De Sousa A. Psychological aspects of paediatric burns (a clinical review). Ann Burns Fire Disasters 2010;23:155159.
83 . Landolt MA, Grubenmann S, Meuli M. Family impact greatest: predictors of quality of life and psychological adjustment in pediatric burn survivors. J Trauma 2002;53:11461151.
84 . Aslakson RA, Curtis JR, Nelson JE. The changing role of palliative care in the ICU. Crit Care Med 2014;42:24182428.
85 . Clarke EB, Curtis JR, Luce JM, Levy M, Danis M, Nelson J, Solomon MZ; Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup Members. Quality indicators for end-of-life care in the intensive care unit. Crit Care Med 2003;31:22552262.
86 . Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, et al.; ATS End-of-Life Care Task Force. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:912927.
87 . Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfield GD, Rushton CH, Kaufman DC; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008;36:953963. [Published erratum appears in Crit Care Med 2008;36:1699.]
88 . Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mulkerin C, Puntillo KA, et al.; Improve Palliative Care in the Intensive Care Unit Project. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med 2010;38:17651772.
89 . Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med 2011;14:1723.
90 . Lupu D; American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 2010;40:899911.
91 . Gagliardi AR, Boyd JM, Evans D, Gerein L, Nathens A, Stelfox HT. Establishing components of high-quality injury care: focus groups with patients and patient families. J Trauma Acute Care Surg 2014;77:749756.
92 . King A, Hoppe RB. “Best practice” for patient-centered communication: a narrative review. J Grad Med Educ 2013;5:385393.
93 . Francesca Monn M, Wang MH, Gilson MM, Chen B, Kern D, Gearhart SL. ACGME core competency training, mentorship, and research in surgical subspecialty fellowship programs. J Surg Educ 2013;70:180188.
94 . Rider EA, Keefer CH. Communication skills competencies: definitions and a teaching toolbox. Med Educ 2006;40:624629.
95 . Hoydt BG. American College of Surgeons commitment statement. Washington, DC: The National Academies [revised 2015 Mar; accessed 2016 Dec 10]. Available from: http://nationalacademies.org/hmd/∼/media/Files/Report%20Files/2014/EOL/Commitment-Statements/American%20College%20of%20Surgeons.pdf?la=en
96 . Cassell J, Buchman TG, Streat S, Stewart RM. Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life—updated. Crit Care Med 2003;31:15511557, discussion 1557–1559.
97 . Schwarze ML, Bradley CT, Brasel KJ. Surgical “buy-in”: the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. Crit Care Med 2010;38:843848.
98 . Aslakson RA, Wyskiel R, Shaeffer D, Zyra M, Ahuja N, Nelson JE, Pronovost PJ. Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis. Crit Care 2010;14:R218.
99 . von Gunten CF, Weissman DE. Consultation etiquette in palliative care #266. J Palliat Med 2013;16:578579.
100 . Nelson JE, Curtis JR, Mulkerin C, Campbell M, Lustbader DR, Mosenthal AC, Puntillo K, Ray DE, Bassett R, Boss RD, et al.; Improving Palliative Care in the ICU (IPAL-ICU) Project Advisory Board. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board. Crit Care Med 2013;41:23182327.
101 . Norton SA, Hogan LA, Holloway RG, Temkin-Greener H, Buckley MJ, Quill TE. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007;35:15301535.
102 . Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest 2003;123:266271.
103 . Lustbader D, Pekmezaris R, Frankenthaler M, Walia R, Smith F, Hussain E, Napolitano B, Lesser M. Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients. Palliat Support Care 2011;9:401406.
104 . Smart NA, Dieberg G, Ladhani M, Titus T. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease. Cochrane Database Syst Rev 2014;6:CD007333.
105 . Weissman DE. Consultation in palliative medicine. Arch Intern Med 1997;157:733737.
Correspondence and requests for reprints should be addressed to Daniel E. Ray, M.D., M.S., Section of Hospice Medicine and Palliative Medicine, 1255 South Cedar Crest Boulevard, Suite 3500, Allentown, PA 18103. E-mail:

The Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project was established with support from the National Institute on Aging (K07-034234 Academic Career Leadership Award [J.E.N.]) and the Center to Advance Palliative Care.

Author Contributions: D.E.R. and M.B.K.: drafted the manuscript. All authors made substantial contributions to the acquisition and interpretation of data (literature review), and all authors made critical revisions to the manuscript and approved the final version for submission.

Author disclosures are available with the text of this article at www.atsjournals.org.

Comments Post a Comment




New User Registration

Not Yet Registered?
Benefits of Registration Include:
 •  A Unique User Profile that will allow you to manage your current subscriptions (including online access)
 •  The ability to create favorites lists down to the article level
 •  The ability to customize email alerts to receive specific notifications about the topics you care most about and special offers
Annals of the American Thoracic Society
14
7

Click to see any corrections or updates and to confirm this is the authentic version of record