End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study.

Ernest Van Veen,Mathieu Van Der Jagt,Hester F Lingsma,Lex Burdorf,David K Menon,Giuseppe Citerio,Jelle L Epker,Andrew I.R Maas,Erwin J.O Kompanje,Nino Stocchetti,Diederik Gommers

doi:10.1016/j.jcrc.2020.04.001

Abstract

We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients. Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients. In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition. We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations.

Highlights

Life-sustaining measures (LSM), such as mechanical ventilation, have allowed physicians to prolong the life of patients
The questionnaire about ethical aspects of the intensive care unit (ICU) was mostly completed by intensivists, neurosurgeons, and neurologists
We aimed to study the variation regarding specific end-of-life (EoL) practices in critically ill traumatic brain injury (TBI) patients, using questionnaires filled in by experts in participating neurotrauma centers

Summary

Introduction

Life-sustaining measures (LSM), such as mechanical ventilation, have allowed physicians to prolong the life of patients. These LSM may sometimes be considered as disproportionate when they postpone unavoidable death and, as a consequence, may only result in prolonged suffering of patients and their relatives. In many countries, it is seen as good medical practice to withhold or withdraw LSM in these situations and allow the patient to die when further treatment is judged as disproportionate [1,2]. Studying variation may provide insight into these issues in patients with traumatic brain injury (TBI) on the intensive care unit (ICU), which can be useful to stimulate discussions regarding EoL best practices, and, development of recommendations [3,17]. Variation may inform comparative effectiveness research (CER), which entails studying the impact of differences in patient management on outcomes to inform best practices

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