Access to Reliable Information about Long-Term Prognosis Influences Clinical Opinion on Use of Lifesaving Intervention

Abstract

BackgroundDecompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI.MethodA two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios.ResultsFive hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] −1.5, 95% confidence interval −1.3 to −1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants.ConclusionsAccess to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.

Using patient admission characteristics alone to predict mortality of critically ill patients: A comparison of 3 prognostic scores

“…We had thus validated the predictive accuracy of these admission prognostic models (AUROC SAPS III 0.836 [16]. Despite a good discrimination and calibration, the predicted risks derived from the SAPS III model or other admission prognostic models should not be used to replace clinical judgement as a triage tool in deciding who should receive life-support therapy, because prognostic models designed for evaluation of groups of ICU patients do not have sufficient sensitivity and specificity to apply to individual patients [17].…”

Outcome Following Decompressive Hemicraniectomy for Malignant Cerebral Infarction

“…Given the uncertainties, retrospective consent seems not to provide a sufficient justification for the procedure, especially when it is believed that the most likely outcome if the patient does survive is that of severe neurological disability, which in sound mind a patient may reject when faced with an antecedent choice. 18 This ethical zone of uncertainty especially applies to patients over 60 years of age because it is in this group of patients that there is controversy about possibly unacceptable outcomes and lack of substantial benefit.…”

“…Assuming those patients with an mRS score of 3 responded positively, among the remaining 25 patients, 16 patients could not walk without assistance, could not take care of their basic bodily needs and did not have sufficient neurocognitive function such that they could answer a relatively simple question. Given what many informed commentators of sound mind would regard as an unacceptable outcome, 18 these findings encourage a reconsideration of the conclusion that survival was increased without an increase in severe disability. One should ask: "Severe disability as assessed by whom?"…”

Use of the CRASH study prognosis calculator in patients with severe traumatic brain injury

“…It is these data, which showed the calibration of the CRASH prognostic model when applied to a local context, rather than the CRASH predicted risks alone, that influenced clinical decision making 6 and has since been used to explore attitudes amongst a wide range of healthcare workers regarding consent for life saving, but not necessarily restorative, surgical intervention. 7,8 It must be recognised that there are limitations when making abstract statements such as ''I would rather die than live with severe disability''. However it must also be acknowledged that competent individuals have a right to make decisions regarding an intervention that affect their health and in this regard consideration must always be given to prognosis in order to ensure that the most likely outcome will be acceptable to the person on whom the intervention is being performed.…”