Page 54 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Indeed, better survival rates were reported in patients with a “false” compared to a “true” GCS of 3 (61% vs. 45%).44
Decisions on treatment intensity and in particular withholding and withdrawal of life-sustaining therapies will clearly affect outcome and mortality rates. A random selection of Canadian TBI patients showed that 70% of all deaths were associated with withdrawal of therapy, half within the first three days.87 In Oslo, 17% of s-TBI patients had treatment limiting decisions, of which the majority (70%) was made within the first 2 days after injury. In 93% of in-hospital deaths, treatment limiting decisions were documented.88 Worryingly, around 80% of physicians felt at best uncomfortable with withdrawal of care decisions and there were major differences among them regarding neuro prognostication and decision-making.89 By early withholding/withdrawal, no chance of recovery is offered. The short term of the decision is worrying, given that although the majority (71.4%) of TBI patients with a favorable outcome followed commands (GCS motor score=6) within 1 week, almost 15% regained that ability for the first time from two weeks after injury.
Premature and inappropriate treatment limiting decisions are of particular concern in the elderly. Elderly vs-TBI patients showed higher mortality (80%, 82%, 100%),20, 53, 54 compared to the whole s-TBI group (53.6-77%).52, 53 In literature a mortality of 78.5% in elderly s-TBI patients was reported, compared to >80% in vs-TBI patients (GCS 3-5) and 92.6% for patients aged>80 years.90 Understandably, high mortality rates contribute to the overall belief that aggressive treatment in the elderly population is not effective. A decrease of treatment intensity can have accompanying negative influence on outcome, forming self-fulfilling prophecies.91, 92 Despite the reported high mortality rates, two studies showed that realizing good outcome in elderly vs-TBI survivors was not impossible (5.9-11%).20, 54 Although severity according to the GCS was lower, a recent meta-analysis reported a similar percentage of 7.9% for elderly s-TBI patients.93
Although surgical intervention can reduce mortality and unfavorable outcome rates, not all studies agree on justifying intervention for vs-TBI patients.18, 52 Guidance from evidence is lacking, as patients aged ≥65 years are not included in most clinical studies and not in the BTF Guidelines, resulting in absence of guidance, subjective critical care and thus treatment variation. This is of increasing concern because TBI is increasing in the elderly population (>65 years old) 2, 94 and because elderly patients often necessitate a different approach. Specific features include mostly a low energy
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