Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II.

Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. This second article discusses practical issues around palliative care for burn patients, such as pain and fluid management, withdrawal of ventilator support and wound care, as well as spiritual and family issues. This paper forms part two, of two narrative reviews on the topic of palliation, end-of-life care and burns. The first part considered concepts, decision-making and communication. It was published in volume 10, issue 2, June 2020, pages 95-98.

Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review.

Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.

Parent knowledge on paediatric burn prevention related to the home environment.

INTRODUCTION: Burns amongst children in South Africa are common and usually occur in the immediate home environment. In surveys many parents have requested ongoing educational burn prevention programs. This exploratory thematic parent orientation study assessed the level of parental knowledge on burn prevention strategies in the home. METHODS: Study populations included: Parent with a burned child admitted to hospital, parents of non-burnt hospital attenders and hospital naive parents unbiased by previous exposure to burns. Participants answered a burn prevention questionnaire consisting of five sections. In this, two pictures depicting the circumstances associated with paediatric burns sustained at home were used, one with 15 potential danger points and one sanitized. There was no educational intervention prior to parents viewing the pictures. RESULTS: There were 268 participants; 72 burnt inpatient, 97 non-burnt outpatients and 99 hospital naive participants. The inpatient population displayed the highest incidence of informal housing. A positive relationship was identified between the overall study population and burns general knowledge and prevention. Educated participants were more knowledgeable about burns and better at identifying risk factors. Knowledge about burns was higher in the outpatient population and the highest in the Naïve group when compared to the Inpatients group (p<0.01). The naïve group scored higher in prior knowledge about burns and burn prevention. Of the potential 15 danger points only four of 72 inpatients and three of 97 outpatients identified more than 80% of the potential danger points as compared to 43 of 99 of the naïve group. The dangling kettle cord, the use of a mug to pour paraffin into a lantern and the child pulling a tablecloth were the most common dangerous aspects identified. We demonstrated a positive correlation between participants' ability to identify potential dangers, identify safe practice and implementing safe practice. CONCLUSION: Our findings show that people living in environments optimal for burn incidents know relatively little about burn prevention strategies. Future intervention needs to not only target the population's behavior but most importantly needs to promote better education models.

Pain indicators for persisting pain in hospitalized infants in a South African setting: an explorative study.

In the developing world, there is a high incidence of human immunodeficiency virus (HIV), gastroenteritis, pneumonia, meningitis, and other inflammatory diseases in infants, the conditions of which may induce persisting pain. The primary objective was to estimate the reliability and validity of the Touch Visual Pain (TVP) scale to measure persisting pain. This prospective observational study was performed in hospitalized 0-3-year-old infants in South Africa. The Numeric Rating Scale (NRS) pain, NRS distress, and the TVP scale were applied and scores were compared. The TVP scale consists of 10 behavioral indicators scored as present or not present. Associations between the different scales were tested with logistic regression analyses. We analyzed 337 assessments in 151 patients. The NRS pain score was 4 or higher in 82 (24%) assessments. The NRS distress score was 4 or higher in 242 (72%) assessments. The mean TVP score was 3.7 (SD = 1.6). Four TVP items were statistically significantly associated with NRS pain; three other TVP items with NRS distress. The behaviors "cry/moaning" and "alertness" were also significantly associated with NRS distress. Two TVP items were not sensitive to assess pain or distress and were replaced in a revised TVP version. We conclude that our study identified sensitive and specific indicators of persisting pain in hospitalized children under the age of 3 years in a South African setting. Psychometric properties of the revised TVP need to be studied before its use in clinical practice can be recommended.

Pediatric palliative care in sub-saharan Africa: a systematic review of the evidence for care models, interventions, and outcomes.

CONTEXT: The progressive disease burden among children in sub-Saharan Africa means the provision of palliative care is essential and should be provided alongside treatment where it is available. OBJECTIVES: To systematically review the evidence for pediatric palliative care models, interventions, and outcomes to appraise the state of the science and inform best practice. METHODS: A systematic review search strategy was implemented in eight electronic databases, the search results reported using a PRISMA statement, and findings tabulated. RESULTS: In terms of evidence of palliative care provision and outcomes, only five articles were identified. These represent a small range of acute, community, and hospice care and offer some limited guidance on the development and delivery of services. CONCLUSION: Pediatric palliative care is a pressing clinical and public health challenge in sub-Saharan Africa. Explicit evidence-based models of service development, patient assessment, and evidence for control of prevalent problems (physical, psychological, social, spiritual, and developmental) are urgently needed. Greater research activity is urgently required to ensure an evidence-based response to the enormous need for pediatric palliative care in sub-Saharan Africa.

How health professionals rate painfulness of childhood injuries and illnesses: a survey study.

Pediatric pain management has become well established in developed countries but may lag behind in developing countries, where potentially painful diseases such as gastroenteritis and meningitis are even more common. This survey asked health care givers in the developed and developing worlds to rate pain intensity of 12 common childhood diseases and to inventory the pharmacological and nonpharmacological treatment modalities in their settings. A survey was distributed online (Surveygizmo 3.0) to pediatric health caregivers who rated perceived painfulness of 12 diseases on a 0 to 10 numerical rating scale or stated that the disease was primarily discomforting in their opinion. Also they inventoried the pharmacological and nonpharmacological interventions they utilize in their setting. Sixty-five respondents completed the survey, of whom almost three thirds (72.3%) came from developed countries. Median painfulness scores ranged from 5 (chickenpox) to 9 (compound tibial fracture). The respondents considered a number of diseases that are more often seen in developing countries as painful. Pediatric pain management in the developing world should be improved in view of the high incidences of potentially painful diseases and the lack of (non)pharmacological interventions.

Aromatherapy massage seems to enhance relaxation in children with burns: an observational pilot study.

OBJECTIVE: This observational pilot study investigated effects of aromatherapy massage in paediatric burn patients. METHODS: The setting was a 17 beds level I burn unit in Cape Town, South Africa. Between January and October 2009 heart rates and respiratory rates of patients who underwent aromatherapy massage sessions were read before and after the sessions. Primary outcomes were decline in heart rates and respiratory rates, a sign of relaxation. Behavioural responses (sleep/awake state, facial expression, body posture) were documented as secondary outcomes. RESULTS: A convenience sample of 71 paediatric burn patients (median age 3 years) underwent a total of 126 massage sessions. Mean heart rate decreased significantly from 118 (SD 20) to 109 (SD 21), t=9.8, p<0.001. Mean respiratory rate decreased significantly from 34 (SD 8) to 30 (SD 8), t=10.2, p<0.001. Most massage sessions (92.8%) elicited positive behaviour to the massage, e.g. the child fell asleep, calmed or asked to continue. Nine patients (7.2%) with a median age of 15 months who underwent a single massage session did not show positive behaviour but cried, wriggled or were distressed. CONCLUSIONS: Aromatherapy massage seems to be a helpful nonpharmacological approach to reduce hospitalized paediatric burn patients' distress. Future studies with better research designs and validated outcome measures should confirm our findings.

Evaluation of pain incidence and pain management in a South African paediatric trauma unit.

OBJECTIVES. To evaluate pain incidence and pain management in a South African paediatric trauma unit, and to compare the usefulness of 5 different assessment tools. DESIGN. A prospective observational study, using the Numerical Rating Scale for pain (NRS pain), Numerical Rating Scale for anxiety (NRS anxiety), the Alder Hey Triage Pain Score (AHTPS), the COMFORT behaviour scale and the Touch Visual Pain Scale (TVPS). All patients were assessed at admission; those who were hospitalised were again assessed every 3 hours until discharge. RESULTS. A total of 165 patients, with a mean age of 5.3 years (range 0 - 13), were included. NRS scores were indicative of moderate to severe pain in 13.3% of the patients, and no pain in 24% at admission. Two-thirds of the patients received no analgesics; for them, NRS pain, AHTPS and TVP scores were lower than the scores for the other children. CONCLUSION. Pain and anxiety incidences in this paediatric trauma unit are relatively low. Implementation of a standard pain assessment tool in the emergency department triage system can improve pain management. The AHTPS is the most promising for use in non-Western settings.