Page 141 - 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
solid conclusions. Admittedly, money that has been spent cannot be used to treat other patients with possibly more effective treatments. This perspective, however, should not be a prominent variable in arguing for, or against early treatment-limiting decisions. Depriving some patients of recovery to an acceptable outcome should be absolutely minimized in societal decision-making.
Nonetheless, there must be a point where TBI is so severe and patient outcome so unacceptable as to justify the enormous associated healthcare costs. Establishing
this point is necessary because healthcare costs increase and healthcare budgets are
limited. Therefore, the cost-effectiveness of interventions should be evaluated, and
weighted to the maximum amount. Limitations on costs to maintain life have already
been set by politicians. For example, the cut-off of cost-effective treatments in The Netherlands is €80.000 per quality adjusted life year. 79 The justification and number
of this cut-off should not be determined solely by politicians, but also involve the 6 contributions of experienced physicians and other health-care professionals.
A commonly perceived advantage of including this economic perspective in decision- making is the objectivity of the criterion to decide whether or not to perform an intervention. We should, however, not forget that focusing on cost-benefit analyses fails to recognize individual aspects of care and the social utility of caring for those most in need. People obtain benefit from the belief that they live in a compassionate and humane society where patients in need will not be ignored merely on the basis of costs.
Acute and chronic care
Because of the chronic consequences of s-TBI, many patients and proxies need adequate lifelong care to optimize outcome. 80, 81 Specialized rehabilitation, long-term care and patience are essential for recovery. 14, 82*, 83, 84** Caretakers and researchers of both subacute and chronic care should collaborate closely and become familiar with the needs, challenges and possibilities along the entire chain of care.
Regrettably, in some healthcare systems, patients without enough progress of recovery during rehabilitation are discharged to nursing homes lacking proper rehabilitation or diagnostic oversight, depriving them of opportunities to recover. 75, 85 This seems unfair, since “normal” recovery processes of patients and their brains still remain largely unknown, and subtle progress is known to be missed due to a physician’ generally poor evaluation. 1*, 28, 59, 60**, 61* Many novel rehabilitation initiatives have been developed, and also improved coping interventions appear now to be more effective. 62, 64*, 85, 86, 87, 88
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