Imaging in the acute brain injured state; Ethical considerations

Abstract

Serious brain injury has a 30% mortality rate, and survivors are commonly disabled and require ongoing care. In Canada, deaths are preceded by decisions to limit care in 70% of cases, and some decisions are made too early for accurate prognostication (Turgeon, 2011). Neurologists have an ethical obligation to provide next-of-kin with accurate diagnostic and prognostic information to inform their decision making. Functional magnetic resonance imaging (fMRI) offers the prospect of improving prediction of outcomes in patients with an indeterminate prognosis, but more evidence is required. Conducting fMRI research involving acutely brain injured patients in the intensive care unit (ICU) is practically difficult and raises ethical issues (Weijer, 2016). Early in the translational trajectory, fMRI ought to be considered a nontherapeutic intervention, and the risks of such interventions must be minimized. Transporting critically ill patients outside the ICU has rates of serious adverse events of 4.2–8.9% and cardiac arrest of 0.34–1.6% (Weijer, 2016). To minimize the incremental risks of research participation, nontherapeutic fMRI scans should be paired with clinically indicated imaging. Informed consent in this setting poses difficult challenges (Bruni, 2019). Informed consent must be obtained from the surrogate decision maker (SDM). SDMs should be approached by a third party who can dedicate substantial time to the consent process, and fMRI should be identified clearly as a nontherapeutic procedure. [1]Bruni T. et al.J Med Ethics. 2019 Feb 25; (pii: medethics-2018-104867)Google Scholar; [2]Turgeon A.F. et al.CMAJ. 2011; 183: 1581-1588Google Scholar; [3]Weijer C. et al.Brain. 2016; 139: 292-299Google Scholar