764 What Do You Think? The Ethics of Treating the Medically and Socially Complicated Patient

Introduction Medically complicated burn patients also often present with complex social situations which raise difficult ethical questions for the providers caring for them. While the four principles of biomedical ethics, respect for autonomy, nonmaleficence, beneficence, and justice help guide medical decision making, providers are often faced with making recommendations that are ethically uncomfortable for them. Methods At the ABA Annual Meeting in 2019, we presented a poster of a case of a medically, socially, and ethically complicated patient who was treated at our verified burn unit about a decade ago. Embedded in the poster was a QR code and weblink that people could scan to get to a 10-item online survey containing questions regarding decision making in the case. For our regional burn conference in September 2019, we asked the organizers to send an email containing a summary of the case and a link to the survey via email to all of those who had registered two weeks before the conference. A summary of the case follows: 47-year-old male with an 81% TBSA burn from a car accident, currently intubated and sedated and unable to participate in medical decision making. He needs four limb amputations, though his chance of long-term survival is ultimately thought to be less than 10–20%; best case scenario is a vent-dependent life with tetraplegia, likely without prosthetics due to skin graft issues. He has a very complicated family situation. Survey questions included those about whether it was medically appropriate to do or not do the amputations, how that appropriateness should be assessed, the extent to which the patient’s previous expressed wishes matter, who the appropriate surrogate is, and whether and to what extent the medical team’s feelings about the situation matter. Results Twelve people at the ABA annual meeting and 17 people from the regional meeting responded to the survey. Every respondent answered every question. While there were some similar responses, there were also those with significant variation. Of note, at the ABA, 50% of respondents felt the evidence needed to withdraw treatment was the same as that needed to continue treatment; 70% of participants at the regional meeting thought this. 25% of respondents at the ABA thought it was extremely important that a decision be made that allows team members to sleep at night; 17.65% of participants at the regional meeting thought this. Conclusions Burn care providers do not agree on important aspects of decision making for patients who are medically, socially, and ethically complicated. Applicability of Research to Practice Further discussion of decision making in burn care is needed to help increase provider comfort in making recommendations for patients who are medically, socially, and ethically complicated.