Variations in decisions for care of patients with brain injury 'disturbing'

May 12, 2010

Treatment decisions involving patients with severe brain injury vary widely between medical institutions and appear to be more driven by hospital and physician practices and priorities. In an article appearing today in the New England Journal of Medicine, physicians at the University of Rochester Medical Center (URMC) argue that providers must take steps to develop a process of communication and decision-making that gives greater weight and voice to the informed preferences of patients and their families.

"The decision whether or not to continue aggressive medical treatment for with severe brain injury requires tough discussions about the benefits and burdens," said URMC neurologist Robert Holloway, M.D., co-author of the article. "Such decisions are often made without a clear understanding of the patient's medical prognosis and with suboptimal input from the patient and family. The possibility that decisions of this magnitude are being overly influenced by factors other than patient values and preferences informed by an understanding of the medical options and potential outcomes should make us cringe."

It is estimated that up to 60 percent of deaths in patients with a severe resulting from a stroke, trauma, or are related in some manner to a decision to withdraw treatment. These cases are unique compared to other forms of treatment withdrawal because patients with brain injuries who receive aggressive life-sustaining treatments sometimes continue to live for months or years. However, outcomes can be difficult to predict early in the treatment process and can range from an early death, to survival with extreme physical and cognitive disability, to the possibility of substantial recovery of cognitive function.

Decisions about treatment continuation or withdrawal are often made without clear input from the patient who is often too impaired to participate. Ideally patients would have made their wishes know in advance, but most have not. In these instances where there is medical uncertainty about prognosis and a lack of clear direction from the patient, the treatment culture and practices of a hospital (and even an individual physician) may play the greatest role in influencing treatment. Financial incentives may also matter as hospitals are highly reimbursed for interventions such as tracheosotomies - a breathing tube surgically inserted in the windpipe - which in some circumstances enhance recovery and in others make stopping treatment even more difficult.

The consequence of these potentially conflicting incentives and priorities is a "large and disturbing variation" in how these decisions are approached, with some hospitals electing to aggressively treat all cases while others lean more toward advocating early withdrawal of treatment.

The right approach, the authors contend, should be a mix of three treatment approaches: 1) some early tracheostomies for patients with a good prognosis to allow them to begin rehabilitation earlier; 2) some time limited trials of continuing aggressive support to see if the patient's neurological situation can clarify; and 3) some early withdrawals of treatment for patients with poor prognosis who clearly would not benefit from this type of intervention under these circumstances. The best hospitals would have a combination of these approaches depending on clinical circumstances and patient preferences.

The authors contend that one of the keys to successfully navigating this decision-making process is to create an environment of open communication between medical teams (neurology, neurosurgery, palliative care) and the patient and their family.

"You not only need to understand the clinical situation with all its uncertainties, but you also need to understand patients' values and preferences in light of their medical prognosis," said Timothy Quill, M.D., a co-author of the article and director of the URMC Center for Ethics, Humanities and Palliative Care. "Sometimes the prognostic evidence is clear enough for decisions to be made. But in those situations where the clinical outcomes are uncertain, evidence-based medicine may need to take a back seat to preference-based medicine."

These conversations are challenging under the best of circumstances, but they have recently been clouded by the highly-charged debate over health care reform. Specifically, the authors point to the need to "get well beyond 'death panel' rhetoric to a more systematic conversation about the potential of invasive medical treatments to do good and to harm patients toward the end of life."

Explore further: Oil-swishing craze: Snake oil or all-purpose remedy?

add to favorites email to friend print save as pdf

Related Stories

Cancer patients are not given enough information

Aug 01, 2008

Two thirds of cancer patients receive little or no information about the survival benefits of having palliative chemotherapy before making a decision about treatment, according to a study published today on bmj.com.

Weighing the Options after Life-Altering Stroke

Mar 12, 2009

(PhysOrg.com) -- Choosing to have aggressive brain surgery after suffering a severe stroke generally improves the patients' lives and allows them to live longer, according to research by neurologists at the ...

Recommended for you

Suddenly health insurance is not for sale

Apr 18, 2014

(HealthDay)— Darlene Tucker, an independent insurance broker in Scotts Hill, Tenn., says health insurers in her area aren't selling policies year-round anymore.

Study: Half of jailed NYC youths have brain injury (Update)

Apr 18, 2014

About half of all 16- to 18-year-olds coming into New York City's jails say they had a traumatic brain injury before being incarcerated, most caused by assaults, according to a new study that's the latest in a growing body ...

Autonomy and relationships among 'good life' goals

Apr 18, 2014

Young adults with Down syndrome have a strong desire to be self-sufficient by living independently and having a job, according to a study into the meaning of wellbeing among young people affected by the disorder.

User comments : 0

More news stories

Filipino tests negative for Middle East virus

A Filipino nurse who tested positive for the Middle East virus has been found free of infection in a subsequent examination after he returned home, Philippine health officials said Saturday.

Study says we're over the hill at 24

(Medical Xpress)—It's a hard pill to swallow, but if you're over 24 years of age you've already reached your peak in terms of your cognitive motor performance, according to a new Simon Fraser University study.

NASA's space station Robonaut finally getting legs

Robonaut, the first out-of-this-world humanoid, is finally getting its space legs. For three years, Robonaut has had to manage from the waist up. This new pair of legs means the experimental robot—now stuck ...

Ex-Apple chief plans mobile phone for India

Former Apple chief executive John Sculley, whose marketing skills helped bring the personal computer to desktops worldwide, says he plans to launch a mobile phone in India to exploit its still largely untapped ...

Egypt archaeologists find ancient writer's tomb

Egypt's minister of antiquities says a team of Spanish archaeologists has discovered two tombs in the southern part of the country, one of them belonging to a writer and containing a trove of artifacts including reed pens ...

Airbnb rental site raises $450 mn

Online lodging listings website Airbnb inked a $450 million funding deal with investors led by TPG, a source close to the matter said Friday.