apies in aged patients when the extent of injury precludes the possibility of survival, or when the patient’s deterioration indicates a lack of response to medical interventions [92, 108, 109]. Defining futility for the older burn patient should be based on the providers’ own experiences, the available literature, and taking into account recent advances that may push the hope for survival [2, 10]. Mortality models are highly useful tools to estimate mortality among groups based on injury and patient characteristics (Table 1) yet do not discriminate well between individual survivors and non-survivors. Mortality models are derived from the recent past data; they are not rules to be strictly observed in order to repeat past achievements in survival. Thus, mortality models alone should not decide who should undergo aggressive treatment and who should not [110]. Focusingourresearcheffortsnotonlyonhospitalization but also long-term outcomes of older burn patients is critically important [111]. A better understanding of the functionality and quality of life of older adults with burns will also help guide medical professionals’ decisions regarding aggressiveness of care, and counseling patients and family members about expected outcomes.

Unless they require mechanical ventilation, severely burn patients can remain alert and cooperative during acute resuscitation. Severely injured patients should be allowed to participate in a shareddecision making process when possible. Shared decision means that the physician discusses with the patient the nature and likely outcome of the patient’s condition, the ramifications of treatment alternatives, and most importantly aims to achieve a consensus about treatment most consistent with the patient’s values. Shared decision respects the principle of patient autonomy, and has gradually replaced the more traditional paternalistic approach in the US and other countries [112, 113]. Shared decision is essential as providers may otherwise be unduly influenced by their own values. Although some providers may forego treatment for themselves if given a low chance of survival, many prospective older patients would choose to undergo aggressive treatment nevertheless [114, 115]. In patients who are not able to participate, providers must rely on the substitute judgment of family members or a designated surrogate in the shared decision process. In decisionally-

impaired patients who lack a surrogate, physicians must provide substitute judgment based on advance directives (if available), or their best estimate of the likelihood for survival and rehabilitation for each individual circumstance. Advance directives, however, are not always helpful as their wording may be too general or vague to address the specific circumstances of illness or injury [116, 117].

Both the process by which end of life decisions are made, and the quality of the communication between providers and family members can contribute to a positive experience [118, 119]. Convening a family conference can be an opportunity for families to receive information in an unhurried manner, present their views, and obtain reassurance that pain and suffering will be alleviated during intensive care [110]. If withdrawal of life support is chosen, the provider should explain the stepwise process of withdrawal to family members before it is initiated. Providers should also offer families available hospital services such as spiritual care and bereavement when available.

Summary of key points and recommendations

Older adults are disproportionately affected by burn injury, especially in high-income countries.

Specific age-related physiologic changes and comorbidities contribute to worse hospitalization outcomes in older compared to younger burn patients.

Acute fluid resuscitation in aged patients should proceed along the same guidelines as younger patients.

Early excision is recommended in older adults with severe burns, although hospitalization outcomes remain far inferior to that of younger adults.

Pain management in geriatric burn patients is challenging because it is often under-diagnosed and undertreated.

Pharmacologic pain treatment should be initiated at smaller doses and carefully titrated for comfort.

Older patients are at high-risk for acute delirium, a risk factor for worse hospitalization and longterm outcomes.

Age alone should not be a criterion to forego acute resuscitation. Each case should be individually assessed for the potential for survival and rehabilitation.

Good communication between providers, patients and surrogates improves the quality of intensive care. End of life decisions should be made following a shared-decision making model.

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Correspondence to: Tam N. Pham, M.D., University of Washington Burn Center, Harborview Medical Center, 325 Ninth Avenue, Box 359 796, Seattle, WA, 98 104, USA, E-mail: tpham94@uw.edu