Background: Relatives looking after a terminally ill family member at home face numerous

Object Decompressive craniectomy (DC) with dural expansion is a life-saving neurosurgical procedure performed for recalcitrant intracranial hypertension due to trauma, stroke, and a multitude of other etiologies. Illustratively, we describe technique and lessons learned using DC for battlefield trauma. Methods Neurosurgical operative logs from service (October 2007 to September 2009) in Afghanistan that detail DC cases for trauma were analyzed. Illustrative examples of frontotemporoparietal and bifrontal DC that depict battlefield experience performing these procedures are presented with attention drawn to the L.G. Kempe hemispherectomy incision, brainstem decompression techniques, and dural onlay substitutes. Results Ninety craniotomies were performed for trauma over the time period analyzed. Of these, 28 (31%) were DCs. Of the 28 DCs, 24 (86%) were frontotemporoparietal DCs, 7 (25%) were bifrontal DCs, and 2 (7%) were suboccipital DCs. Decompressive craniectomies were performed for 19 penetrating head injuries (13 gunshot wounds and 6 explosions) and 9 severe closed head injuries (6 war-related explosions and 3 others). Conclusions Thirty-one percent of craniotomies performed for trauma were DCs. Battlefield neurosurgeons use DC to allow for safe transfer of neurologically ill patients to tertiary military hospitals, which can be located 8–18 hours from a war zone. The authors recommend the L.G. Kempe incision for blood supply preservation, large craniectomies to prevent brain strangulation over bone edges, minimal brain debridement, adequate brainstem decompression, and dural onlay substitutes for dural closure.

Despite medical therapy, most patients with moderate to severe chronic obstructive pulmonary disease, interstitial lung disease and cystic fibrosis experience pain, fatigue and dyspnoea, with the majority not getting relief from dyspnoea towards the end of life. Furthermore, dyspnoea causes social isolation and difficulty performing activities of daily living and impairs quality of life. There is an increasing evidence base for the assessment of supportive and palliative care needs, symptom interventions, prognostication, models of service delivery and implications of these for clinical practice and research in non-malignant lung diseases. WHAT IS UNKNOWN: Despite advances, much still remains unknown regarding assessment, management and prognostication in individual chronic non-malignant lung diseases. Although different service models are being used in clinical practice, the optimal model(s) of service delivery remain unknown. IMPLICATION FOR FUTURE RESEARCH, POLICY AND PRACTICE: We describe key areas for further research, which include the need for large, high-quality trials of pharmacological and non-pharmacological interventions and their combinations as well as evaluation of the efficacy and cost-effectiveness of models of care. As access to palliative care is poor for these patients, the barriers to referral need to be understood and reduced, which along with effective working between palliative care teams, with respiratory services backup, should optimise delivery of care in patients with life-limiting non-malignant lung disease.