Page 233 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

negative feedback makes other involved carers (i.e. nurses) pessimistic, which can result in limited care efforts, which in turn negatively influences patient outcome. 77
Not realizing their own contribution, worse outcome will initially confirm their individual beliefs and later spread by the inclusion in clinical studies or when included in prognostic models. 77 As much as 63% of deaths in trials investigating s-TBI patients were registered after decisions to withdraw life-sustaining therapies. 78 Trial mortality rates could have been influenced by this large number of withdrawals, and could further contribute to maintain the belief in poor prognosis, resulting in more withdrawals of care and worse outcome. 78 Physicians need to be aware of this self- fulfilling prophecy and its potential effect on treatment decision-making. 79
Some restraint in treatment-limiting decisions in the acute phase might be prudent given the uncertainties on patient outcome prediction and outcome valuation and the irreversible consequences of these decisions.
Can we fix the acute treatment decision-making process?
Acute treatment decision-making in s-TBI patients is highly complex and many problems with uncertainty in outcome prediction and outcome valuation will be difficult to solve. Despite this complexity, physicians will continue to make treatment decisions at the best of their abilities. An improvement in the quality of these inevitable acute treatment decisions could be achieved by deliberately delaying early treatment- limiting decisions in s-TBI patients with substantial prognostic uncertainty. This may not only prevent premature treatment-limiting decisions, but also means that these patients will receive optimal acute treatment, which hopefully allows best possible recovery, probably at the cost of increasing neuro-critical care costs.
The necessity for more time
The proposed strategy provides more time to measure and collect early key critical care variables to improve prognostic ability and to reconstruct a patients’ preferences, values, and treatment whishes. 31,80-82 This valuable information on clinical progress, neurological recovery, and a complete, objective and consistent evaluation of rapidly evolving imaging modalities (i.e. CT and MRI) only becomes available with extra time and will substantially improve diagnostics and prognostication. 83-86 More time also allows multidisciplinary counsel including moral deliberation on individual patient or proxy preferences. All this additional information is highly valuable, and indispensable for a decision-making process. 31,87,88
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General discussion and future perspectives
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