Page 135 - 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
INTRODUCTION
Many patients who sustain severe traumatic brain injury (s-TBI) die after trauma or
survive with (severe) disabilities. 1*, 2, 3*, 4*, 5 Performing lifesaving (surgical) interventions
may result in survival, but there is no common opinion on how to define an unfavorable
outcome, nor on the time horizon of assessing such outcome. 5, 6, 7, 8, 9* Treatment-limiting
decisions likely result in clinical deterioration and death. 10, 11, 12** Most acute treatment
decisions are poorly supported by high-quality evidence and prognostic algorithms,
leaving shared decision-making complex. 8, 13*, 14, 15* Perhaps in light of such lack of clarity,
non-adherence to guidelines and substantial treatment variation remains pervasive. 16, 17, 18*
Therefore, we examine such treatment paradoxes by reviewing the literature and
reporting on several interdisciplinary panel meetings that focused on clinical decision- 6 making in initiating or withholding (surgical) intervention to patients after s-TBI. This
position paper was written following a series of discussions with an expert panel of professionals from different backgrounds, and should serve as a starting point for
further discussions rather than constitute a final outcome process.
Professional code of physicians
Physicians practice medicine by working according to several codes of conduct and by
following four universally accepted moral principles in medical ethics (Table 1). 19, 20, 21, 22, 23
Autonomy of the patient is inherently compromised in patients with s-TBI, and proxies are often absent during the acute phase, improperly designated, or incapable of substitute informed decision-making. 24*, 25, 26** Physicians then are responsible for selecting a strategy they consider in line with a patients’ best interests, i.e. beneficence. However, both medical and surgical or procedural interventions carry risks of inducing harm, creating a difficult equilibrium between beneficence and non-maleficence. 2, 9*, 27, 28 Lastly, justice requires the fair distribution of benefits, risks and limited medical goods and services. As such, resources should ethically be restricted when used on so-called ineffective and disproportional treatment efforts, as it will deprive other patients of potentially effective treatments
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