Page 139 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Focus groups on clinical decision-making in severe traumatic brain injury
outcome based on clinical expertise and subjective evaluations with ill-defined clinical endpoints. 45 Yet, it is considered common sense that lifesaving interventions should be withheld when the predicted risk of ‘unfavorable’ outcome is high, while depriving a patient of a possible favorable outcome can be seen as inappropriate care. The approach to treat all patients with the potential to survive inherently includes the risk of survival with an unacceptable outcome. All physicians should appreciate and communicate the existing multi-dimensional uncertainty, and decisions should not be guided by assumptions that falsely confer a sense of certainty. 29*, 33**
The risk of selection bias and self-fulfilling prophecies should be noted. Assumptions on poor prognosis that lead to treatment-limiting decisions and probably contribute to a worse outcome and possibly death in selected cases. 12**, 33**, 70
Improving prognostication 6 In clinical care the estimated prognosis is based on clinical characteristics, subjective
evaluation of the clinician and contextual information at a short interval post onset.
However, prognosis after s-TBI is dynamic in which the passage of time changes the
predicted probability of a favorable outcome. 71*, 72 In case of prognostic uncertainty and a small chance of ‘acceptable’ outcome, full critical care treatment should be initiated and continued to allow for best possible recovery. Information on clinical progress, neurological recovery, the patient’s treatment and outcome preferences (when necessary through proxies), and multidisciplinary discussion (ideally with moral council) need to be included in decision-making - and this information only becomes available with time.
Striving for personalized care is promising and allows for appreciation of the general injury applied in an individualized context. 73 In the subacute phase, frequent re-evaluation and communication are essential; when treatment has become disproportionate, given the outcome, withdrawal of life-sustaining measures can be considered even at later moments in time. Despite the associated increased healthcare consumption and costs, the survival of patients with severe disabilities and the longer period of suffering for patients/proxies can be legitimized if more patients survive with acceptable outcome.
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