Abstract
BackgroundDecompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI.MethodA two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios.ResultsFive hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] −1.5, 95% confidence interval −1.3 to −1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants.ConclusionsAccess to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.
Highlights
Decompressive craniectomy has been assumed to be a lifesaving rescue treatment in severe traumatic brain injury (TBI) and ischaemic stroke, when severe brain swelling is not responsive to conservative medical therapy [1,2,3,4,5]
Recent trials on decompressive craniectomy for patients with ischaemic stroke have, demonstrated that the procedure increases the number of survivors and the number of patients with a favourable functional outcome [8,9,10]
By combining the prognostic variables of age, Glasgow coma scale (GCS), pupillary reaction, extracranial injuries and radiological appearances, the CRASH trial collaborators have gone some way to address this issue by developing a user friendly webbased outcome prediction model that has been internally and externally validated in both high and low income countries [23]. By applying this model to a population-based cohort of patients who have had a decompressive craniectomy in Western Australia, we have demonstrated that the model was not perfectly calibrated, it did provide an objective index of injury severity and the likely functional outcome at 18 months after using decompressive craniectomy as a lifesaving procedure for severe TBI [14,15]
Summary
Decompressive craniectomy has been assumed to be a lifesaving rescue treatment in severe traumatic brain injury (TBI) and ischaemic stroke, when severe brain swelling is not responsive to conservative medical therapy [1,2,3,4,5]. Recent trials on decompressive craniectomy for patients with ischaemic stroke have, demonstrated that the procedure increases the number of survivors and the number of patients with a favourable functional outcome [8,9,10]. Decompressive craniectomy is considered as a lifesaving procedure [14,15], used when intracranial pressure (e.g. Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers’ opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI
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