For professionals

Abstract

Purpose of the assessment
There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce practice variability, and improve shared proxy decision-making.

Recent findings
Clinical decision-making about initiating, continuing, and discontinuing medical treatment can have significant consequences and lead to presumed benefits for the patient. Unfortunately, such decisions are often not transparent and can be controversial in nature. The entire decision-making process is often characterized by both a lack of objective criteria and the lack of validated prognostic models that could predict relevant outcome measures, such as long-term quality and life satisfaction. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been treated with ongoing aggressive medical care, and surgical or other procedural interventions have been undertaken in the pursuit of a more favorable outcome for the patient. Given this spectrum of care offered to identical patient cohorts, there is a clear need to identify and reduce existing selectivity, and to better establish the objective criteria that are useful for more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome.

Summary
Recent efforts by multiple medical groups have helped reduce uncertainty and improve care and outcomes throughout the healthcare chain. While an unbounded pursuit to sustain life may seem unrealistic, treatment-limiting decisions should not deprive patients of the opportunity to achieve an outcome they would have deemed acceptable.

Keywords
Decision Making, End of Life, Medical Ethics, Prognosis, Traumatic Brain Injury