Outcome from Severe Neurological Illness; Should it Influence Medical Decisions?

Abstract

Most persons now accept the concept that when brain is dead, self is dead, and are willing to act accordingly. Much more difficult is to decide what to do when illness irreparably deprives the brain of cognitive functions. To facilitate less impassioned discussion of this question, 500 consecutive patients in coma from non-traumatic causes have been studied in the USA and Europe and the outcome has been compared against carefully selected early neurological signs. Medical coma was itself a dangerous sign, with only 15% of patients recovering independence within the first month. Within the first six hours, when most medical decisions are made about applying intensive care, neurological signs predicted with 95% confidence between the extremes of favourable and unfavourable outcomes in as many as a quarter of the patients. Only 5% of patients who failed to regain cognition by the end of one week regained any independence. Other more detailed guidelines were equally informative. If prognostic signs that confidently separate potentially favourable from unfavourable outcomes can be identified in severe neurological illness, perhaps society can more easily help medicine in reaching difficult ethical decisions.