Page 235 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

6 were highly regarded experts in the field, clinical situations might not be similar to the Dutch situation and their expert opinion might not be shared. This could limit the generalizability and practicality of the list, but emphasises that continued discussions and research on treatment-limiting decisions are essential.
Textbox 1: Reasons, including potential outcome perspectives, to strongly consider treatment-limiting decisions (chapter 6) 47
The societal perspective
Second, treatment can be considered disproportional from a societal perspective. Healthcare is not only about individuals but also about improving health of populations. 12-14,32 The proposed strategy of providing acute treatment to more s-TBI patients is likely to substantially increase in-hospital costs. On a large scale, this might affect restricted healthcare budgets and jeopardize vulnerable healthcare systems or societal health. 3,103 This is undesirable in a time where politicians are already struggling to restrict the increasing worldwide economic burden of healthcare. 103 Despite governmental restrictions, The Netherlands, with 17.3 million inhabitants
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General discussion and future perspectives
1. Brain death, from a patient’s perspective (not considering interests regarding organ donation procedures). 99,100
2. (chronic) Unresponsive wakefulness syndrome. 96,101
3. Minimally conscious state – (minus) (i.e. visual pursuit, localization of noxious
stimuli, appropriate smiling or crying to emotional stimuli). 101,102
4. Anavailable,unquestionable,writtenandsignedspecificadvancedirectiveof the patient that prohibits treatment in a specific situation (possibly related to
expected outcome).
5. A proxy opinion that is unquestionably based on patient preferences and
that is not in conflict with the attending medical teams’ considerations, that prohibits treatment in a specific situation (possibly related to expected outcome).
6. A patient’s view (or when necessary a reconstructed vision through surrogated) on life and quality of life is contrary to the outcome that can be expected from the best available prognostic models.
7. From a societal perspective, treatment costs along the whole chain of care that are not cost-effective and higher than the maximum amount that has been decided by national legislation.
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