Page 136 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 6
Table 1: Moral principles in medical ethics
Principle
1. Autonomy 2. Beneficence
3. Nonmaleficence 4. Justice
Description
A norm of respecting and supporting autonomous decisions.
A group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs.
A norm of avoiding the causation of harm.
A group of norms for fairly distributing benefits, risks, and costs.
Treatment-limiting decisions
Treatment-limiting decisions, including withholding lifesaving (surgical) interventions or withdrawal of life-sustaining medical treatment, are sometimes made within the first two days after s- TBI, allowing for, and leading to death, further deterioration and depriving patients a chance for recovery. 10, 12**, 29* Furthermore, defining recovery is relative, as it may encompass the entire spectrum from saving a patients’ life, achieving good health related quality of life, to entire satisfaction with one’s recovery. 1*, 4*, 30, 31*, 32*
Although withdrawal of life-sustaining measures can be morally justified, and in line with patients’ and proxies’ preferences and values, it should be noted that such decisions are typically based on non-data driven clinical prognostication and the goal of achieving survival with an imprecisely defined ‘favorable’ outcome. 33** As ‘favorable’ outcome has been reported in even some of the most severely injured patients, treatment-limiting decisions in patients that might have achieved ‘favorable outcome’ must therefore arguably be difficult to uphold on ethical and moral grounds. 2, 4*
Reasons for treatment-limiting decisions
Several recent studies have aimed to identify what specific reasons or values constitute decision-making in severe brain injuries by medical teams, proxies or patients, but much remains unexplained. 10, 12**, 18*, 34*, 35, 36 Physicians are likely to include their personal valuation of predicted patient outcome in their treatment considerations based on a mix of factors such as religious background, personal and clinical experience, culture, national legislation, and even the socio- economic status of the patient. 18*, 37 This introduces the risk of selectivity and is not evidence- based medicine. 18*
To elaborate on this, the authors, specialists in neurosurgery, intensive care medicine, rehabilitation, chronic care, anthropology and medical-ethics, executed a multiple occasion professionally led focus group discussion. We explored and described the process and reasoning of decision-making in this manuscript and propose several reasons that would legitimize treatment- limiting decisions (Table 2).
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