Page 229 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

can have disastrous clinical consequences. It remains unknown how high this accuracy must be and what cut-offs should be used for decision-making. There are peer reviewed recommendations that consider it reasonable to pursue non-aggressive care in patients with a >85% chance of death or ‘unfavourable’ outcome. 34 If a physician would have followed this recommendation, a 28-year old patient with a CRASH- model predicted risk of death at 14 days of 91.8% and a risk of an ‘unfavourable outcome’ at 6 months of 95.7%, that achieved ‘favourable’ outcome and was able to live independently, would have probably died after treatment-limiting decisions. 48
Despite many efforts to improve outcome prediction, there is substantial inaccuracy in todays’ prognostic abilities. Every effort must be made to prevent that patients are unfairly deprived of potentially beneficial care because of erroneous prognostication or poorly chosen cut-offs. It is therefore essential that inherent uncertainties of outcome prediction are acknowledged in the acute decision-making process. Only the best possible approximation of expected patient outcome should be used and opportunities to improve prognostic accuracy should be explored.
Patient outcome valuation
Valuation of predicted patient outcome is about judging the favourability of a patients’ future health status and about defining how ‘acceptable’ or ‘unacceptable’ that health status is to patients, proxies and societies. Its importance for acute treatment decision-making seems obvious. Common sense dictates that acute treatment should be initiated or continued when outcome is judged ‘acceptable’, and withheld or discontinued when outcome is judged ‘unacceptable’.
A cut-off point for ‘acceptability’ of outcome would be useful, but an exact definition of ‘acceptable’ or ‘unacceptable’ outcome remains elusive, and is probably impossible to determine. 49,50 Any cut-off point will be highly arbitrary and can never account for the countless outcome possibilities and numerous variations in peoples’ specific contexts, and ever-changing desires or interpretations of well-being or ‘the good life’. Life can be judged worth sustaining because it has intrinsic value to relatives and friends, or because of cultural or religious reasons. 51 (chapter 6)
Several scales and checklists have been developed to quantify the individual and societal impact of TBI, and to improve the assessment of medical treatment efficacy. 52 Nonetheless, the most frequently used measures have important limitations in specifying the individual ‘acceptability’ of outcome. The reliability of
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General discussion and future perspectives
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