Page 234 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 12
Although delaying treatment-limiting decisions seems to be a viable solution to improve decision-making, it is not common practice. Treatment-limiting decisions are reported within 2 days after injury in up to 70% of s-TBI patients. 78,89,90 Although physicians have best intentions, these early decisions deprive patients of a chance for succesfull recovery and usually result in clinical deterioration and death. 78,89 Limiting treatment within 2 days after injury seems to be disproportional and morally unjustified given the uncertainties on future outcome. 82
It remains unknown how much extra time is necessary to sufficiently improve prognostic accuracy to avoid the withholding of potentially beneficial treatments. The Neurocritical Care Society recommends to use a 72-hour observation period for devastating brain injury patients to determine clinical response and delay decisions regarding withdrawal of life-sustaining treatment. 91 Longer decision-making intervals of a week or even 10 days have also been recommended, awaiting adequate control of cerebral edema, injurious neuroinflammation, and associated intracranial hypertension. 92,93 Delaying any conclusions about prognosis to after 72 hours is also advised for brain injury after cardiac arrest. 94
Treatment-limiting decisions
There are advantages of the proposed strategy, but an unrestricted endeavour for sustaining life by providing optimal acute treatment to all s-TBI patients is undesirable and unrealistic for two main reasons:
First, providing acute treatment might be considered disproportional from a patients perspective. Treatment can be against patients’ and proxies’ preferences and values. 78,89,95 When achieved outcome becomes ‘unacceptable’, or when a combination of different features indicates very low chances of regaining an ‘acceptable’ outcome, or when treatment has become disproportionate given the outcome, treatment-limiting decisions should be considered. Treatment-limiting decisions can be inevitable and morally justified. Death is unwanted, but catastrophic conditions such as unresponsive wakefulness syndrome or minimally conscious state are accompanied by very severe disabilities and enormous challenges for both patients and proxies that should not be disregarded. 96,97 Many will doubt this is a human life worth living. 98 (chapter 6)
Several reasons to consider early treatment-limiting decisions are listed in textbox 1 (chapter 6). 47 This list is meant to serve as a starting point for further discussion, rather than constitute a final list of reasons. Although all focus group participants from chapter
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