Page 138 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 6
lifesaving/sustaining interventions in all patients, but suggests that physicians should acknowledge that an unacceptable outcome in their opinion may not necessarily be unacceptable to patients.
Determining cut-off points of acceptability is highly arbitrary and nearly impossible because of countless outcome possibilities and substantial variation in peoples’ ever- changing desires and interpretations of a ‘good life’. For instance, a life could be worth sustaining regardless of any favorability classifications because it has intrinsic value to relatives and friends, or because of cultural or religious reasons. 48*
Prognostic uncertainty
Accurate outcome prediction remains unavailable, although it has huge consequences on decision-making and it is crucial for patients, proxies and physicians. 18*, 35, 45, 49, 50 Physicians are frequently unable to make accurate predictions and although prognostication may be considered straightforward at the extremes of the spectrum, it remains difficult in the middle. 29*, 36, 45 This is disturbing, since a physician’s perception on long-term prognosis likely influences treatment decisions. The long-term physical, cognitive, emotional and behavioral outcome after TBI is determined by injury characteristics as well as by contextual factors of the patient and the caregiver. Such issues are not covered in the CRASH and IMPACT prognostic models that focus on mortality and severe disability at 6 months post injury. Although helpful in estimating survival, these models do not cover outcomes such as independence in daily living and ultimately perceived satisfaction with life. 45*, 51, 52, 53*, 54**
The reasons for failure of prediction are; (1) the heterogeneous nature of s-TBI and concurring comorbidities and their unknown effect on outcome; 50, 55, 56*, 57 (2) unclear/ incomplete clinical information, including a patient’s neurological state or level of consciousness; 58, 59 (3) largely unknown pathophysiological mechanisms of brain injury and inherent degree of plasticity; 50, 60**, 61*, 62, 63, 64* (4) prediction models do not include long-term (health-related) QOL, although long-term outcome changes have been reported and patients/proxies value this outcome; 3*, 28, 31*, 65, 66 (5) prediction models are based on large retrospective data sets that do not necessarily reflect current or future treatment strategies. 8, 67, 68*, 69
Balancing between beneficence and non-maleficence in clinical decision-making after s-TBI is a process of weighing the chance between favorable and non-favorable
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