Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

Abstract

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

Variability in Diagnosing Brain Death at an Academic Medical Center

“…Devastating brain injuries are well-recognized causes leading to irreversible cessation of neurological function and eventual brain death [1]. The Uniform Determination of Death Act (UDDA) in 1981 legally established brain death as “irreversible cessation of all functions of the entire brain, including the brain stem” [2].…”

Palliative Care Consultations in the Neuro-ICU: A Qualitative Study

“…8 Recent guidelines from the neurocritical care society recommend implementing palliative care for patients with devastating brain injury in the neuro-ICU and their surrogates. 9 However, the exact indication or best timing for specialist palliative care consultations in the neuro-ICU is unknown, and studies exploring how palliative care issues present in the neuro-ICU are limited.…”

Observations on Ethical Issues in the Neuro-ICU

“…As Becker and colleagues first showed in patients with massive intracerebral hemorrhage [8], DNR orders and orders to reduce LST early in the patient's course led to the self-fulfilling prophecy of death. As revealed in the studies summarized by Souter et al [1], withholding or withdrawing LST became the most common cause of death in these patients. I concur with their advice to delay decisions to withdraw LST until 72 h have elapsed (except in the most extreme cases) to allow a determination of clinical response.…”

“…In this issue of Neurocritical Care, Souter et al from the Neurocritical Care Society report their recommendations for optimizing the management of patients with devastating brain injuries [1]. They analyzed evidence and expert opinion to formulate best practices for several aspects of neuro-ICU care.…”