When treating patients with burns, ethical considerations for patient autonomy should be considered and honored surrounding the cosmetic outcome of treatments.

In a case study published in the AMA Journal of Ethics, Yuk Ming Liu, MD, clinical assistant professor at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City, Iowa, and Kathleen Skipton Romanowski, MD, assistant professor at the University of California Davis, examine the ethical issues surrounding the care of a burn patient who is unable to indicate her wishes.

The case in question involves a 30-year-old news anchor who was injured in a car accident and sustained third- and fourth-degree burns covering 40% of her total body surface, including her face, scalp, and neck. She requires extensive facial grafting and reconstruction and will likely have partial vision loss and partial bilateral loss of nose, ear, and hair tissue. With good care, she is expected to be functional in 6 to 12 months; however, her wishes to proceed or not are unclear, as she is currently sedated, and she does not have healthcare power of attorney.

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Her parents favor continued aggressive care, but one nurse expresses concern about the degree of the role of the patient’s parents in making decisions. She notes that the patient ran away at 17, and her parents have only been marginally involved in her life since then. Friends contend that the patient would not want to go through the pain and suffering involved in recovery only to be disfigured in the end.

The authors review the ethical issues of this case, including the difficulty in knowing what a patient would want even when there is no legally appointed surrogate and the importance of cosmetic and functional outcomes when it comes to end-of-life care decisions. Another important issue is how burn professionals should respond when cosmetic concerns are suggested as a reason to withdraw life-prolonging therapies.

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Although healthcare surrogates can be helpful in these situations, the authors admit that many healthcare surrogates are not aware of their patient’s preferences. The authors suggest that a consensus between the 2 parties who are invested in the patient’s outcome — parents and friends — would be ideal in this case, and indicate that the process of consensus building might benefit from engaging an institution’s ethics committee.

Drs Liu and Romanowski also suggest that in a case such as this, contacting patients in the burn community may provide perspective on the issue, as many burn victims go through changes in outlook on life after the trauma and recovery period. They note that what the patient might have previously thought was important may no longer be of importance to her.

The authors conclude by noting that the most ethically sound decision would be to continue aggressive treatment until the patient is able to participate in decisions about her care and the value that she now places on cosmetic outcomes.


Liu YM, Romanowski KS. Should cosmetic outcome influence discussion about goals of care for severely burned patients? AMA J Ethics. 2018;40:546-551.