Withdrawing life-support in critically-ill adults with brain injuries

Severe brain injury is the leading cause of disability among young Canadians. Many end up in the Intensive Care Unit (ICU) on life support. Their families often face the difficult decision to withdraw care, especially when they are otherwise healthy with no pre-existing conditions. Doctors too find these situations challenging, according to a study published Monday in the Canadian Medical Association Journal.

Acquired traumatic brain injury refers to the sudden damage that comes most commonly from a violent blow or jolt to the head. Typical causes include car or motorcycle collisions, falls, sports injuries, assaults as well as penetrating injuries from gunshot wounds. Drownings can lead to severe damage caused by lack of oxygen to the brain.

As shown recently on White Coat, Black Art, fentanyl and other opioid overdoses can also lead to brain injuries from lack of oxygen and possibly other related causes.

In general, the patients admitted to the ICU are older (in their 70s and 80s) and have chronic heart and other problems that contribute to a poor quality of life. The decision to withdraw life support in these patients is often based on their pre-existing health and quality of life.

The patients with severe traumatic brain injury are often young (most commonly children up to four years of age and adolescents ages 15 to 19 with a spike of cases age 60 and older) and otherwise healthy. The decision to withdraw life support is not based on their pre-existing condition but on their long-term prognosis from their injuries.

Previous studies by Dr. Alexis F. Turgeon and fellow researchers with the Canadian Traumatic Brain Injury Research Consortium and the Canadian Critical Care Trials Group showed large variations in the death rate and the timing of death among patients with traumatic brain injuries at ICUs across Canada. The patients generally arrive in the ICU on life support. Many of these patients die shortly after they’re taken off the ventilator.

In previous studies, the researchers also found large variations in the timing of the decision to withdraw life support, with half of all deaths following withdrawal of life support taking place during the first three days of ICU care.  As the authors of the study suggested, that may be too soon for family members (with advice from critical care doctors) to decide to withdraw life support because it’s far too soon to get an accurate long-term prognosis. At that stage, doctors tend to disagree on the prognosis.

The latest study was designed to explore what’s behind those disagreements.

The researchers interviewed 20 ICU physicians across Canada who care for patients with severe traumatic brain injuries. They looked for factors that helped explain why some physicians recommend withdrawing life support early on while others recommend waiting longer to decide.

(CMAJ)

The patients’ injuries and evidence of severe brain damage were important factors. Most of those interviewed said they were aware of published guidelines on when and how to withdraw care. All said they were influenced by the patient and their family.

Patients with severe brain injuries don’t usually speak for themselves, so any indication of the patient’s prior stated wishes was crucial. Other important factors that influenced the doctor’s decision was their experience in withdrawing life support.

Nearly all said they were influenced by what their colleagues would do in the same situation.

Difficult decisions

Some factors were identified that increase the stress that health professionals feel surrounding the withdrawal of life support. One is a difference of opinion between the doctor and the patient and family over the withdrawal of life support. Physician want to consider fully the previous wishes stated by the patient while weighing-in based on their knowledge and experience.

Another source of conflict and stress occurs when the family is decisive about withdrawal of life-support while the physician wants more time to think it over because of uncertainty regarding the prognosis.

Some of the doctors said they got anxious about getting the prognosis correct because of the stakes. Colleagues who chime in with extreme anecdotes of patients who woke up intact against all odds make some doctors second-guess themselves. If team members looking after the patient have conflicting opinions about what to do, that tends to delay the withdrawal of life-support until everyone is on board.

The authors say physicians involved in these challenging decisions need better evidence to predict accurately the quality of life that patients are likely to have should they recover enough to be discharged from the ICU. That would make recommendations on withdrawing life-prolonging care easier. They would also benefit from more experience during their training years so they’re less anxious when they graduate.

The system needs to find a way to create more time for doctors to make the most accurate prognosis possible, to discuss differences of opinion on the health-care team and to reach a consensus.

Finally, the first few hours and days in the ICU are mostly about treating severe injuries and dealing with medical complications. To make better recommendations, the study shows that critical care people need to learn more about the values and preferences of the patient.

That means not just knowing the medical details. It also means getting to know the person receiving life-support.

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