Abstract

When information on a coma patient’s expected outcome is uncertain, a moral dilemma arises in clinical practice: if life-sustaining treatment is continued, the patient may survive with unacceptably poor neurological prospects, but if withdrawn a patient who could have recovered may die. Continuous electroencephalogram-monitoring (cEEG) is expected to substantially improve neuroprognostication for patients in coma after cardiac arrest. This raises expectations that decisions whether or not to withdraw will become easier. This paper investigates that expectation, exploring cEEG’s impacts when it becomes part of a socio-technical network in an Intensive Care Unit (ICU). Based on observations in two ICUs in the Netherlands and one in the USA that had cEEG implemented for research, we interviewed 25 family members, healthcare professionals, and surviving patients. The analysis focuses on (a) the way patient outcomes are constructed, (b) the kind of decision support these outcomes provide, and (c) how cEEG affects communication between professionals and relatives. We argue that cEEG can take away or decrease the intensity of the dilemma in some cases, while increasing uncertainty for others. It also raises new concerns. Since its actual impacts furthermore hinge on how cEEG is designed and implemented, we end with recommendations for ensuring responsible development and implementation.

Highlights

  • Based on observations in two Intensive Care Unit (ICU) in the Netherlands and one in the USA that had Continuous electroencephalogram-monitoring (cEEG) implemented for research, we interviewed 25 family members, healthcare professionals, and surviving patients

  • We argue that cEEG can take away or decrease the intensity of the dilemma in some cases, while increasing uncertainty for others

  • Since its actual impacts hinge on how cEEG is designed and implemented, we end with recommendations for ensuring responsible development and implementation

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Summary

Aim and Motivation

“My husband, Chris, had been alone since 9 am. We had almost reached home when he called me in distress ‘Where are you? I need you’. In the case of prognostication of patients in post-anoxic coma, continuous electroencephalogram (cEEG) monitoring was recently shown to reduce prognostic uncertainty. It provides reliable predictions of poor outcome, and enables a robust predictor of good outcome [12,13,14,15]. Based on the evidence available, cEEG monitoring was recently considered sufficiently robust to be included in the Dutch clinical guidelines for prognostication of patients in post-anoxic coma [29]. We will unpack both issues by reconstructing what is required to produce cEEG-based test results

Epileptic activity
Activity level
Good Good
Linking Measurements to Outcomes
Responding to Uncertain Outcomes
No prognostic tools SSEP cEEG
Visualization of Results
Timing of Disclosure of Prognostic Outcome
Summing up and Looking Forward
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