Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group

Buse Sarigul, Randy S. Bell, Randall Chesnut, Sergio Aguilera, Andras Buki, Giuseppe Citerio, D. Jamie Cooper, Ramon Diaz-Arrastia, Michael Diringer, Anthony Figaji, Guoyi Gao, Romergryko G. Geocadin, Jamshid Ghajar, Odette Harris, Alan Hoffer, Peter Hutchinson, Mathew Joseph, Ryan Kitagawa, Geoffrey Manley, Stephan A. MayerDavid K. Menon, Geert Meyfroidt, Daniel B. Michael, Mauro Oddo, David O. Okonkwo, Mayur B. Patel, Claudia Robertson, Jeffrey V. Rosenfeld, Andres M. Rubiano, Juan Sahuquillo, Franco Servadei, Lori Shutter, Deborah D. Stein, Nino Stocchetti, Fabio Silvio Taccone, Shelly D. Timmons, Eve Tsai, Jamie S. Ullman, Paul Vespa, Walter Videtta, David W. Wright, Christopher Zammit, Gregory W.J. Hawryluk*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

11 Scopus citations

Abstract

Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.

Original languageEnglish
Pages (from-to)1707-1717
Number of pages11
JournalJournal of Neurotrauma
Volume40
Issue number15-16
DOIs
StatePublished - 1 Aug 2023
Externally publishedYes

Keywords

  • SIBICC
  • brain injury
  • nihilism
  • prognosis
  • survey
  • withdrawal of care

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