Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations

Miranda, Stephen P.; Morris, Rachel; Rabas, Mackenzie; Creutzfeldt, Claire J.; Cooper, Zara

doi:10.1007/s12028-023-01764-8

Cited by 8 publications

(2 citation statements)

References 124 publications

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“…Further, increased age is attributed to an increased postoperative risk of complications and a poorer outcome compared to younger patients ( 40 , 84 , 124–126 ). Physical and cognitive recovery is possible and uncertain in older adults ( 127 ). Current studies, however, distinguish between chronological age and frailty, which is described as an age-related cumulative decline in the functionality of physiological systems ( 128 ).…”

Section: Discussionmentioning

confidence: 99%

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Kapapa,

Jesuthasan,

Schiller

et al. 2024

Front. Med.

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ObjectiveGlobally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients.MethodsA retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05.ResultsA total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894–0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429).ConclusionEven under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient’s will.

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Section: Discussionmentioning

confidence: 99%

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Kapapa,

Jesuthasan,

Schiller

et al. 2024

Front. Med.

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“…Given that prognostic markers may become more accurate with time (eg, examination and neuroimaging markers), some guidelines suggest waiting 72 hours after injury . However, given that consciousness recovery may be more substantially delayed, other guidelines suggest waiting at least 28 days after injury before confidently concluding a poor prognosis, prompting more regular consideration of time-limited trials . Second, when neuroprognostication is ultimately conducted to inform decisions about LST, clinicians not only must predict a patient’s future neurologic function but also must consider what level of neurologic function would be acceptable to them .…”

Section: Applying Multimodal Prognostic Markers To Icu Practicementioning

confidence: 99%

Coma Prognostication After Acute Brain Injury

Fischer,

Edlow

2024

JAMA Neurol

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ImportanceAmong the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain’s functional and structural integrity.ObservationsPrognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient’s current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery.Conclusions and RelevanceNeuroprognostic markers are rapidly evolving as new ways of assessing the brain’s structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient’s values.

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Delayed Withdrawal of Life-Sustaining Treatment in Disorders of Consciousness: Practical and Theoretical Considerations

Williams,

Bass,

Hampton

et al. 2024

Neurocrit Care

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Disorders of consciousness (DoC) resulting from severe acute brain injuries may prompt clinicians and surrogate decision makers to consider withdrawal of life-sustaining treatment (WLST) if the neurologic prognosis is poor. Recent guidelines suggest, however, that clinicians should avoid definitively concluding a poor prognosis prior to 28 days post injury, as patients may demonstrate neurologic recovery outside the acute time period. This practice may increase the frequency with which clinicians consider the option of delayed WLST (D-WLST), namely, WLST that would occur after hospital discharge, if the patient’s recovery trajectory ultimately proves inconsistent with an acceptable quality of life. However acute care clinicians are often uncertain about what D-WLST entails and therefore find it difficult to properly counsel surrogates about this option. Here, we describe practical and theoretical considerations relevant to D-WLST. We first identify post-acute-care facilities to which patients with DoC are likely to be discharged and where D-WLST may be considered. Second, we describe how clinicians and surrogates may determine the appropriate timing of D-WLST. Third, we outline how D-WLST is practically implemented. And finally, we discuss psychosocial barriers to D-WLST, including the regret paradox, in which surrogates of patients who do not recover to meet preestablished goals frequently choose not to ultimately pursue D-WLST. Together, these practical, logistic, and psychosocial factors must be considered when potentially deferring WLST to the post-acute-care setting to optimize neurologic recovery for patients, avoid prolonged undue suffering, and promote informed and shared decision-making between clinicians and surrogates.

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Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations

Cited by 8 publications

References 124 publications

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Coma Prognostication After Acute Brain Injury

Delayed Withdrawal of Life-Sustaining Treatment in Disorders of Consciousness: Practical and Theoretical Considerations

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