Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center

Abstract

BackgroundTreatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting.MethodsA retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs.ResultsTLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1–652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients’ preferences were found in only 7% of cases.DiscussionClinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting.ConclusionTLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.

Outcome in Patients with Isolated Moderate to Severe Traumatic Brain Injury

“…There are only four studies that have published rates of WLST in this group of patients. In-hospital mortality rates amongst patients with moderate to severe TBI varied between 10.8% and 44.1%, whilst the WLST rates ranged between 45.0% and 86.6% in these studies: likely due to geographical and cultural differences [ 1 , 5 , 14 , 15 ]. Verkade et al [ 8 ] looked at WLST rates in a Dutch ICU.…”

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

“…Instead, treatment-limiting decisions in s-TBI are common in some countries and often made within the first 2 days after trauma [ 35 , 50 ]. Limiting treatment offers no serious chance of recovery and regularly results in quick death [ 35 , 50 ]. We acknowledge that these decisions are sometimes inevitable and could be in a patients’ best interest when there is no realistic chance to achieve a “favorable” outcome.…”

“…Neurosurgical evacuation of the hematoma, sometimes with additional decompressive craniectomy (DC), can save patients’ lives by decreasing intracranial pressure and preventing secondary edema, ischemia, and inflammatory cell death, but at the same time, it may result in the survival of severely disabled patients [ 16 , 23 ]. Alternatively, early treatment-limiting decisions (TLD) reduce any chance of recovery and normally result in death [ 35 , 50 ]. To assist physicians in these difficult life-or-death decisions, experts in the field have provided statements and guidelines on the preferred treatment strategies in these patients [ 4 , 5 ].…”

Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital

“…Compared to other articles on EOL decisions after TBI, 30,31 our ICU is a late decision center: EOL decisions were taken on average 7 days after TBI, similar to the timing reported in a recent article referring to patients with intracranial hemorrhage. 32 We think that this period of aggressive treatment before redirection of care permits adequate observation of the evolution of the damage to better define prognosis.…”

“…In our population, ADs (14.0%, 95% CI, 6.6%-27.3%) and discussions about EOL issues with relatives before trauma (34.9%, 95% CI, 22.4%-49.8%) were rare, as was also found in a recent paper performed in a Norwegian center. 31 This is probably due to the sudden nature of TBI 34 and the relative young age of the study population. Older patients with chronic illnesses are more likely to face the topic.…”