A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries

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Abstract

<p class="first" id="d5687030e122">Early prognostication in patients with a devastating brain injury is not always accurate and can lead to inappropriate decisions. We present case histories to support the recent recommendations of the Neurocritical Care Society that treatment withdrawal decisions should be delayed by up to 72 h in these patients. Development of pathways incorporating these recommendations can improve prognostication, enhance end of life care given to these patients and their families, and increase the opportunities to explore the donation wishes of more patients. They may also standardise the approach to decision making in the same way as the recommendations for management of patients after out of hospital cardiac arrest have done. </p>

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Most cited references 7

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Effect of regression to the mean on decision making in health care.

Veronica Morton, D Torgerson (2003)

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Survival following liver transplantation from non-heart-beating donors.

John Abt, James Markmann, Judith Forman … (2003)

To determine whether patient and graft survival following transplantation with non-heart-beating donor (NHBD) hepatic allografts is equivalent to heart-beating-donor (HBD) allografts. With the growing disparity between the number of patients awaiting liver transplantation and a limited supply of cadaveric organs, there is renewed interest in the use of hepatic allografts from NHBDs. Limited outcome data addressing this issue exist. Retrospective evaluation of graft and patient survival among adult recipients of NHBD hepatic allografts compared with recipients of HBD livers between 1993 and 2001 using the United Network of Organ Sharing database. NHBD (N = 144) graft survival was significantly shorter than HBD grafts (N = 26856). One- and 3-year graft survival was 70.2% and 63.3% for NHBD recipients versus 80.4% and 72.1% (P = 0.003 and P = 0.012) for HBD recipients. Recipients of an NHBD graft had a greater incidence of primary nonfunction (11.8 vs. 6.4%, P = 0.008) and retransplantation (13.9% vs. 8.3%, P = 0.04) compared with HBD recipients. Prolonged cold ischemic time and recipient life support were predictors of early graft failure among recipients of NHBD livers. Although differences in patient survival following NHBD versus HBD transplant did not meet statistical significance, a strong trend was evident that likely has relevant clinical implications. Graft and patient survival is inferior among recipients of NHBD livers. NHBD donors remain an important source of hepatic grafts; however, judicious use is warranted, including minimization of cold ischemia and use in stable recipients.

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Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary.

Massimo Antonelli, J Pimentel, Josephine Hill … (2004)

The purpose of the conference was to provide clinical practice guidance in end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record. Presenters and jury were selected by the sponsoring organizations (American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, Société de Réanimation de Langue Française). Presenters were experts on the question they addressed. Jury members were general intensivists without special expertise in the areas considered. Experts presented in an open session to jurors and other healthcare professionals. Experts prepared review papers on their specific topics in advance of the conference for the jury's reference in developing the consensus statement. Jurors heard experts' presentations over 2 days and asked questions of the experts during the open sessions. Jury deliberation with access to the review papers occurred for 2 days following the conference. A writing committee drafted the consensus statement for review by the entire jury. The 5 sponsoring organizations reviewed the document and suggested revisions to be incorporated into the final statement. Strong recommendations for research to improve end-of-life care were made. The jury advocates a shared approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the team, to decide on the reasonableness of the planned action. If a conflict cannot be resolved, an ethics consultation may be helpful. The patient must be assured of a pain-free death. The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double-effect" should not detract from the primary aim to ensure comfort.

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Author and article information

Journal

Title: Journal of the Intensive Care Society

Abbreviated Title: Journal of the Intensive Care Society

Publisher: SAGE Publications

ISSN (Print): 1751-1437

Publication date Created: October 25 2016

Publication date Created: November 2016

Publication date (Electronic): July 08 2016

Publication date (Print): November 2016

Volume: 17

Issue: 4

Pages: 295-301

Affiliations

[1 ]North Bristol NHS Trust, Bristol, UK

[2 ]Wye Valley NHS Trust, Hereford, UK

[3 ]University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

Article

DOI: 10.1177/1751143716647980

PMC ID: 5624473

PubMed ID: 28979514

SO-VID: b8c5a628-71da-4451-ba33-991222bfcf17

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http://journals.sagepub.com/page/policies/text-and-data-mining-license

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A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries

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Most cited references 7

Effect of regression to the mean on decision making in health care.

Survival following liver transplantation from non-heart-beating donors.

Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary.

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