Page 105 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Outcome versus in-hospital costs: a neurosurgical paradox?
even considered unsalvageable. 3,28,29 Nevertheless, neurosurgical intervention was
performed in up to 98% of patients with s-TBI. This percentage is high compared to
other studies, but seems rational, since neurosurgical evacuation of the hematoma and/
or DC can be lifesaving and prevent secondary injury by decreasing ICP. 2,3,6,32 The high
percentage can also be explained by the specific selection of patients with a t-ASDH
where neurosurgical consultation was considered necessary, suggesting a higher vulnerability. Although the present study did not evaluate treatment effectiveness, a
separate analysis by the authors seemed to support the more aggressive approach.
21 Even so, superiority between hematoma evacuation or DC remains unknown and 4 no clinical trial has proven primary DC to be effective in improving patient outcome.
4,33 Surgical intervention is even controversial because patients may survive with ‘unacceptable’ severe disabilities with an accompanying high burden on proxies and society. 5 This is fundamental in neurosurgical treatment decision-making and as a result, a ‘surgical’ treatment strategy as seen in this study, which follows the guidelines, is not standard day-to-day care in all hospitals. 3,10,21,32
Instead, treatment limiting decisions in s-TBI are common in some countries and often made within the first 2 days after trauma. 7,8 Limiting treatment offers no serious chance of recovery and regularly results in quick death. 7,8 We acknowledge that these decisions are sometimes inevitable and could be in a patients’ best interest when there is no realistic chance to achieve a “favourable” outcome. But what can be considered a favourable or an unfavourable outcome after s-TBI and vs-TBI?
Therefore, according to the investigators, it would be catastrophic to limit or withhold treatment in patients that could have still benefitted from it. Physicians should be careful in making early treatment limiting decisions when there is still uncertainty, because uncertainty implies a possibility for favourable outcome. Unfortunately, uncertainty in predicting who will benefit from what treatment is very common. There is substantial variation in the perception of neurologic prognosis among physicians and high treatment variation. 10,12,34 In line with some literature, we believe that treatment limiting decisions in the early phase cannot be justified, because prognostication is not yet accurate enough. 35 In a later stage, when clinical and neurological improvement remain absent, further treatment might be considered futile with more certainty. Then, treatment limiting decisions should be discussed with all involved healthcare professionals and proxies.
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