The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study

Tanizaki, Shinsuke; Toma, Yasuo; Miyashita, Katsuyoshi; Maeda, S.

doi:10.1016/j.wnsx.2022.100144

Cited by 3 publications

(2 citation statements)

References 22 publications

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“…However, this would not apply to specific situations in which neurological damage is so catastrophic that functional recovery is extremely unlikely. Remarkably, a recent study from Japan demonstrated that almost all WLST decisions were made through discussions between patients’ family members and attending emergency physician intensivists/neurosurgeons within 24 h after admission for severe traumatic brain injury [ 27 ]. Early WLST decision in our study may be in part attributed to the physician’s perception of futility that the patient would have a poor neurological prognosis or a “bridge to nowhere.” It is also speculated that attending physicians/families decided WLST with the self-fulfilling prophecy that the patient would have an unfavorable outcome.…”

Section: Discussionmentioning

confidence: 99%

Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation

et al. 2023

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Background Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR. Methods We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined. Results We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p < 0.001). Primary cerebral disorders as cause of cardiac arrest and higher severity of illness at intensive care unit admission were associated with WLST decisions. Conclusion For approximately one-third of ECPR/OHCA patients, WLST was decided during admission, mainly because of perceived unfavorable neurological prognoses. Decisions and neurological assessments for ECPR/OHCA patients need further analysis.

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Section: Discussionmentioning

confidence: 99%

Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation

et al. 2023

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“…Because of its complex pathophysiology and commonly related intra and extracranial significant injuries, ASDH is still considered one of the most lethal TBI, despite recent advances in the patient transfer, diagnostic modalities, sophisticated neurointensive care and neurosurgical management [2,4,6]. Regrettably, the mortality and poor outcome rates did not differ significantly from the early CT published reports till up-to-date studies from 50-80%, while functional recovery ranged from 20-40% [1,2,[6][7][8][9][10][11][12][13]. It is still unclear which surgical technique is the optimal treatment strategy for traumatic ASDH.…”

Section: Introductionmentioning

confidence: 97%

Surgical Management of Traumatic Acute Subdural Hematoma

El-Gaidi

Shaban²

2023

Zagazig University Medical Journal

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Background: Traumatic acute subdural hematoma (ASDH) remains one of the most fatal traumatic brain injuries, despite recent advances in neurosurgical management. Nevertheless, the optimum surgical approach is still unclear. Hinged craniotomy (HC) and decompressive craniectomy (DC) are the most commonly adopted surgical techniques. The aim of this study is to evaluate the suitability, indications, outcome, and complications of HC and DC. Methods: A retrospective case series including 45 patients with ASDH with Glasgow Coma Scale (GCS) 4-12. HC was performed (group I, 16 patients) when the brain was relaxed. If the brain was not relaxed significantly, DC was preferred in 29 patients (intermediate category, group II, 13 patients) or bulging brain (group III, 16 patients). The clinical, radiological, and surgical data and complications were analyzed, and Glasgow Outcome Scale (GOS) score was documented after 6 months of follow-up. The poor outcome included scores 1-3, while functional survivors included scores 4 and 5. Results: The overall functional survivor rate was 11/45 (24.4%), while poor outcome and mortality rates were (75.6%) and (48.9%) respectively. The functional survivors across the 3 groups were comparable. There was no significant difference regarding the outcome between HC (5/16) and DC (6/29) (p > 0.05). Conclusions: Both HC and DC were viable surgical options with no difference in the outcomes and complications following the evacuation of traumatic ASDH for relaxed and bulging brains respectively. Patients with intermediate brain condition are managed according to the surgeon's preference and facility equipment, especially the availability of ICP monitoring.

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Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers

Niemeyer,

Jochems,

Van Ditshuizen

et al. 2024

Eur J Trauma Emerg Surg

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Purpose With an increasingly older population and rise in incidence of traumatic brain injury (TBI), end-of-life decisions have become frequent. This study investigated the rate of withdrawal of life sustaining treatment (WLST) and compared treatment outcomes in patients with isolated TBI in two Dutch level-I trauma centers. Methods From 2011 to 2016, a retrospective cohort study of patients aged ≥ 18 years with isolated moderate-to-severe TBI (Abbreviated Injury Scale (AIS) head ≥ 3) was conducted at the University Medical Center Rotterdam (UMC-R) and the University Medical Center Utrecht (UMC-U). Demographics, radiologic injury characteristics, clinical outcomes, and functional outcomes at 3–6 months post-discharge were collected. Results The study population included 596 patients (UMC-R: n = 326; UMC-U: n = 270). There were no statistical differences in age, gender, mechanism of injury, and radiologic parameters between both institutes. UMC-R patients had a higher AIShead (UMC-R: 5 [4–5] vs. UMC-U: 4 [4–5], p < 0.001). There was no difference in the prehospital Glasgow Coma Scale (GCS). However, UMC-R patients had lower GCSs in the Emergency Department and used more prehospital sedation. Total in-hospital mortality was 29% (n = 170), of which 71% (n = 123) occurred after WLST. Two percent (n = 10) remained in unresponsive wakefulness syndrome (UWS) state during follow-up. Discussion This study demonstrated a high WLST rate among deceased patients with isolated TBI. Demographics and outcomes were similar for both centers even though AIShead was significantly higher in UMC-R patients. Possibly, prehospital sedation might have influenced AIS coding. Few patients persisted in UWS. Further research is needed on WLST patients in a broader spectrum of ethics, culture, and complex medical profiles, as it is a growing practice in modern critical care. Level of evidence Level III, retrospective cohort study.

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The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study

Cited by 3 publications

References 22 publications

Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation

Prevalence, reasons, and timing of decisions to withhold/withdraw life-sustaining therapy for out-of-hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation

Surgical Management of Traumatic Acute Subdural Hematoma

Clinical outcomes and end-of-life treatment in 596 patients with isolated traumatic brain injury: a retrospective comparison of two Dutch level-I trauma centers

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