Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations

Abstract

Patients with severe grades of life-threatening brain injury are commonly characterized as having devastating brain injury (DBI), which we have defined as: 'any neurological condition that is assessed at the time of hospital admission as an immediate threat to life or incompatible with good functional recovery AND where early limitation or withdrawal of therapy is being considered'. The outcome in patients with DBI is often death or severe disability, and as a consequence rapid withdrawal of life sustaining therapies is commonly contemplated or undertaken. However, accurate prognostication in life-threatening brain injury is difficult, particularly at an early stage. Evidence from controlled studies to guide decision-making is limited, and there is a risk of a 'self-fulfilling prophecy', with early prognostication leading to early withdrawal of life sustaining therapies and death. The Joint Professional Standards committee of the Faculty of Intensive Care Medicine and the Intensive Care Society convened a consensus group with representation from stakeholder professional organizations to develop clear professional guidance in this area. It recognized that the weak evidence base makes GRADE guidelines difficult to justify. We have made 12 practical, pragmatic recommendations to help clinicians deliver safe, effective, equitable, and justifiable care within resource constrained healthcare systems. In the situation where patient-centred outcomes are recognized to be unacceptable, regardless of the extent of neurological improvement, then early transition to palliative care is appropriate. These recommendations are intended to apply where the primary pathology is DBI, rather than where DBI has compounded a progressive and irreversible deterioration in other life-threatening comorbidities.

European Academy of Neurology guideline on the diagnosis of coma and other disorders of consciousness

“…It is thus unsurprising that as many as 40% of non‐communicating patients with DoC may be wrongly classified as being in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) . This has major ethical and practical implications for patients and their caregivers, including prognosis, treatment, resource allocation and end‐of‐life decisions .…”

Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2018

“…14 Smith 15 reviewed neuromonitoring in TBI and Harvey et al have provided some guidance to physicians caring for those with devastating brain injury via a consensus statement including direction on the decision to transition to palliative care. 16 Cordonnier et al have summarized the current management of acute ICH. 17 Finally, excellent discussions of the anesthetic care for patients undergoing novel functional and laser ablation neurosurgical procedures were provided by Dunn et al and Jimenez-Ruiz et al 18,19…”

Organization of a Neurointensive Care Unit

“…Consensus guidelines recommend using a 72-hour observation period to determine clinical response and delaying decisions regarding withdrawal of therapy in the meantime. 13 Families of such patients value consistent and compassionate delivery of information by the treating team. The presence of family support specialists may improve communication as well as family satisfaction.…”