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Wtorek P, Weiss MJ, Singh JM, Hrymak C, Chochinov A, Grunau B, Paunovic B, Shemie SD, Lalani J, Piggott B, Stempien J, Archambault P, Seleseh P, Fowler R, Leeies M. Beliefs of physician directors on the management of devastating brain injuries at the Canadian emergency department and intensive care unit interface: a national site-level survey. Can J Anaesth 2024; 71:1145-1153. [PMID: 38570415 PMCID: PMC11269388 DOI: 10.1007/s12630-024-02749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024] Open
Abstract
PURPOSE Insufficient evidence-based recommendations to guide care for patients with devastating brain injuries (DBIs) leave patients vulnerable to inconsistent practice at the emergency department (ED) and intensive care unit (ICU) interface. We sought to characterize the beliefs of Canadian emergency medicine (EM) and critical care medicine (CCM) physician site directors regarding current management practices for patients with DBI. METHODS We conducted a cross-sectional survey of EM and CCM physician directors of adult EDs and ICUs across Canada (December 2022 to March 2023). Our primary outcome was the proportion of respondents who manage (or consult on) patients with DBI in the ED. We conducted subgroup analyses to compare beliefs of EM and CCM physicians. RESULTS Of 303 eligible respondents, we received 98 (32%) completed surveys (EM physician directors, 46; CCM physician directors, 52). Most physician directors reported participating in the decision to withdraw life-sustaining measures (WLSM) for patients with DBI in the ED (80%, n = 78), but 63% of these (n = 62) said this was infrequent. Physician directors reported that existing neuroprognostication methods are rarely sufficient to support WLSM in the ED (49%, n = 48) and believed that an ICU stay is required to improve confidence (99%, n = 97). Most (96%, n = 94) felt that providing caregiver visitation time prior to WLSM was a valid reason for ICU admission. CONCLUSION In our survey of Canadian EM and CCM physician directors, 80% participated in WLSM in the ED for patients with DBI. Despite this, most supported ICU admission to optimize neuroprognostication and patient-centred end-of-life care, including organ donation.
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Affiliation(s)
- Piotr Wtorek
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Health Sciences Centre, JJ399-820 Sherbrook St., Ann Thomas Building, Winnipeg, MB, R3A 1R9, Canada.
| | - Matthew J Weiss
- Transplant Québec, Montreal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Division of Critical Care, Department of Pediatrics, Centre Mère-Enfant Soleil du CHU de Québec, Quebec City, QC, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Carmen Hrymak
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba, Gift of Life Program, Shared Health Manitoba, Winnipeg, MB, Canada
| | - Alecs Chochinov
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brian Grunau
- Department of Emergency Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Bojan Paunovic
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | | | | | - James Stempien
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Patrick Archambault
- Department of Anesthesiology and Critical Care, Université Laval, Laval, QC, Canada
| | - Parisa Seleseh
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Rob Fowler
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - Murdoch Leeies
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba, Gift of Life Program, Shared Health Manitoba, Winnipeg, MB, Canada
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Hautmann X, Rohde V, von der Brelie C. Clinical Course after End-of-Life Decisions on a Neurosurgical Ward: Much to Learn and Improve. J Neurol Surg A Cent Eur Neurosurg 2024. [PMID: 38959942 DOI: 10.1055/s-0043-1771278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND End-of-life (EoL) decisions are routine in neurosurgical care due to frequent devastating and life-threatening diagnoses. Advance directives, discussions with patients' relatives, and evaluation of the alleged will of the patient play an increasing important role in clinical decision-making. Institutional standards, ethical values, different ethnical backgrounds, and individual physician's experiences influence clinical judgments and decisions. We hypothesize that the implementation of palliative care in neurosurgical wards needs optimization. The aim of this study is to identify possible sources of error and to share our experiences. METHODS This is a retrospective observational analysis. One hundred and sixty-eight patients who died on a regular neurosurgical ward between 2014 and 2019 were included. Medical reports were analyzed in detail. A differentiation between consistent and nonconsistent palliation was made, with consistent palliative care consisting of discontinuation of medication that was no longer indicated, administration of medication for symptom control, and consequent discontinuation of nutrition and fluid substitution that went beyond satisfying hunger or thirst. RESULTS EoL decisions were made in 127 (84.1%) of all 168 cases; 100 patients were included in our analysis. Of these patients, only 24 had an advance directive, and the relatives were included in the communication about the therapy goals in 71 cases. Discontinuation of medication that is not for symptom control was performed in 63 patients, food withdrawal in 66 patients, and fluid substitution that went beyond the quenching of thirst was withdrawn in 27 patients. Thus, consistent palliative care was realized in 25% of all patients. The mean duration from the EoL decision until death was 2.1 days (range: 0-20 days). If a consistent palliative care was carried out, patients survived significantly shorter (nonconsistent palliative care: 2.4 days; range: 0-10 days vs. consistent palliative care: 1.2 days; range: 0-4 days; p = 0.008). CONCLUSIONS The therapy goal should be thoroughly considered and determined at an early stage. If an EoL decision is reached, consistent palliative care should be carried out in order to limit suffering of moribund patients.
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Affiliation(s)
- Xenia Hautmann
- Department of Neurosurgery, Georg August University Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg August University Göttingen, Göttingen, Germany
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Sanders WR, Barber JK, Temkin NR, Foreman B, Giacino JT, Williamson T, Edlow BL, Manley GT, Bodien YG. Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis. J Neurotrauma 2024. [PMID: 38739032 DOI: 10.1089/neu.2024.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Among patients with severe traumatic brain injury (TBI), there is high prognostic uncertainty but growing evidence that recovery of independence is possible. Nevertheless, families are often asked to make decisions about withdrawal of life-sustaining treatment (WLST) within days of injury. The range of potential outcomes for patients who died after WLST (WLST+) is unknown, posing a challenge for prognostic modeling and clinical counseling. We investigated the potential for survival and recovery of independence after acute TBI in patients who died after WLST. We used Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) data and propensity score matching to pair participants with WLST+ to those with a similar probability of WLST (based on demographic and clinical characteristics), but for whom life-sustaining treatment was not withdrawn (WLST-). To optimize matching, we divided the WLST- cohort into tiers (Tier 1 = 0-11%, Tier 2 = 11-27%, Tier 3 = 27-70% WLST propensity). We estimated the level of recovery that could be expected in WLST+ participants by evaluating 3-, 6-, and 12-month Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale outcomes in matched WLST- participants. Of 90 WLST+ participants (80% male, mean [standard deviation; SD] age = 59.2 [17.9] years, median [IQR] days to WLST = 5.4 [2.2, 11.7]), 80 could be matched to WLST- participants. Of 56 WLST- participants who were followed at 6 months, 31 (55%) died. Among survivors in the overall sample and survivors in Tiers 1 and 2, more than 30% recovered at least partial independence (GOSE ≥4). In Tier 3, recovery to GOSE ≥4 occurred at 12 months, but not 6 months, post-injury. These results suggest a substantial proportion of patients with TBI and WLST may have survived and achieved at least partial independence. However, death or severe disability is a common outcome when the probability of WLST is high. While further validation is needed, our findings support a more cautious clinical approach to WLST and more complete reporting on WLST in TBI studies.
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Affiliation(s)
- William R Sanders
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Jason K Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
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Sullivan MD, Owattanapanich N, Schellenberg M, Matsushima K, Lewis MR, Lam L, Martin M, Inaba K. Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients. Injury 2023; 54:111088. [PMID: 37833232 DOI: 10.1016/j.injury.2023.111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST. METHODS The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients. RESULTS Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h. CONCLUSIONS More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.
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Affiliation(s)
- Michael D Sullivan
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Natthida Owattanapanich
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Matthew Martin
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
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Ketharanathan N, Hunfeld MAW, de Jong MC, van der Zanden LJ, Spoor JKH, Wildschut ED, de Hoog M, Tibboel D, Buysse CMP. Withdrawal of Life-Sustaining Therapies in Children with Severe Traumatic Brain Injury. J Neurotrauma 2023. [PMID: 36475884 DOI: 10.1089/neu.2022.0321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Neuroprognostication in severe traumatic brain injury (sTBI) is challenging and occurs in critical care settings to determine withdrawal of life-sustaining therapies (WLST). However, formal pediatric sTBI neuroprognostication guidelines are lacking, brain death criteria vary, and dilemmas regarding WLST persist, which lead to institutional differences. We studied WLST practice and outcome in pediatric sTBI to provide insight into WLST-associated factors and survivor recovery trajectory ≥1 year post-sTBI. This retrospective, single center observational study included patients <18 years admitted to the pediatric intensive care unit (PICU) of Erasmus MC-Sophia (a tertiary university hospital) between 2012 and 2020 with sTBI defined as a Glasgow Coma Scale (GCS) ≤8 and requiring intracranial pressure (ICP) monitoring. Clinical, neuroimaging, and electroencephalogram data were reviewed. Multi-disciplinary follow-up included the Pediatric Cerebral Performance Category (PCPC) score, educational level, and commonly cited complaints. Seventy-eight children with sTBI were included (median age 10.5 years; interquartile range [IQR] 5.0-14.1; 56% male; 67% traffic-related accidents). Median ICP monitoring was 5 days (IQR 3-8), 19 (24%) underwent decompressive craniectomy. PICU mortality was 21% (16/78): clinical brain death (5/16), WLST due to poor neurological prognosis (WLST_neuro, 11/16). Significant differences (p < 0.001) between survivors and non-survivors: first GCS score, first pupillary reaction and first lactate, Injury Severity Score, pre-hospital cardiopulmonary resuscitation, and Rotterdam CT (computed tomography) score. WLST_neuro decision timing ranged from 0 to 31 days (median 2 days, IQR 0-5). WLST_neuro decision (n = 11) was based on neurologic examination (100%), brain imaging (100%) and refractory intracranial hypertension (5/11; 45%). WLST discussions were multi-disciplinary with 100% agreement. Immediate agreement between medical team and caregivers was 81%. The majority (42/62, 68%) of survivors were poor outcome (PCPC score 3 to 5) at PICU discharge, of which 12 (19%) in a vegetative state. One year post-injury, no patients were in a vegetative state and the median PCPC score had improved to 2 (IQR 2-3). No patients died after PICU discharge. Twenty percent of survivors could not attend school 2 years post-injury. Survivors requiring an adjusted educational level increased to 45% within this timeframe. Chronic complaints were headache, behavioral problems, and sleeping problems. In conclusion, two-thirds of sTBI PICU mortality was secondary to WLST_neuro and occurred early post-injury. Median survivor PCPC score improved from 4 to 2 with no vegetative patients 1 year post-sTBI. Our findings show the WLST decision process was multi-disciplinary and guided by specific clinical features at presentation, clinical course, and (serial) neurological diagnostic modalities, of which the testing combination was determined by case-to-case variation. This stresses the need for international guidelines to provide accurate neuroprognostication within an appropriate timeframe whereby overall survivor outcome data provides valuable context and guidance in the acute phase decision process.
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Affiliation(s)
- Naomi Ketharanathan
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maayke A W Hunfeld
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marcus C de Jong
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Lineke J van der Zanden
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Matthijs de Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Corinne M P Buysse
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
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Tanizaki S, Toma Y, Miyashita K, Maeda S. The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study. World Neurosurg X 2022; 17:100144. [PMID: 36353247 PMCID: PMC9637969 DOI: 10.1016/j.wnsx.2022.100144] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/27/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution. METHODS A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST. RESULTS Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24 h of admission. The mean duration between WLST and death was 2 days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24 h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST. CONCLUSIONS The decisions of almost all WLST cases were made within 24 h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients' religious and cultural backgrounds.
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Affiliation(s)
- Shinsuke Tanizaki
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan,To whom correspondence should be addressed: Shinsuke Tanizaki, M.D.
| | - Yasuo Toma
- Department of Neurosurgery, Fukui Prefectural Hospital, Fukui, Japan
| | | | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
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Mansour T, Beck B, Gabbe B, Farhat I, Belcaid A, Neveu X, Moore L. International comparison of injury care structures, processes, and outcomes between integrated trauma systems in Québec, Canada, and Victoria, Australia. Injury 2022; 53:2907-2914. [PMID: 35688707 DOI: 10.1016/j.injury.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Quality improvement activities in trauma systems are widely based on comparisons between trauma centers within the same system. Comparisons across different trauma systems may reveal further opportunities for quality improvement. OBJECTIVES This study aimed to compare the integrated trauma systems in Québec, Canada and in Victoria, Australia, regarding their structures, care processes and patient outcomes. METHODOLOGY The elements recommended by the American College of Surgeons were used to compare trauma systems structures. Comparisons of care processes and patient outcomes were based on data from major trauma admissions extracted from trauma registries (2013 and 2017). Care processes included time to reach a definitive care facility, time spent in the emergency department, and time lapsed before the first head computed tomography (CT) scan. These care processes were compared using a z-test of log-transformed times. Hospital mortality and hospital length of stay (LOS) were compared using indirect standardization based on multiple logistic and linear regression. RESULTS Major differences in trauma system structure were Advanced Trauma Life Support at the scene of injury (Victoria), the use of validated prehospital triage tools (Québec), and mandatory accreditation of all trauma centers (Québec). Patients in Québec arrived at their definitive care hospital earlier than their counterparts in Victoria (median: 1.93 vs. 2.13 h, p = 0.002), but spent longer in the emergency department (median: 8.23 vs. 5.15 h, p<0.0001) and waited longer before having their first head CT (median: 1.90 vs. 1.52 h, p<0.0001). In-hospital mortality and hospital LOS were higher in Québec than in Victoria (standardized mortality ratio: 1.15, 95% CI: 1.09 - 1.20; standardized LOS ratio: 1.10, 95% CI: 1.09 - 1.11). CONCLUSION We observed important differences in the structural components and care processes in Québec and Victoria's trauma systems, which might explain some of the observed differences in patient outcomes. This study shows the potential value of international comparisons in trauma care and identifies possible opportunities for quality improvement.
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Affiliation(s)
- Thowiba Mansour
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada; Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Imen Farhat
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Québec, QC, Canada
| | - Amina Belcaid
- Institut National d'Excellence en Santé et en Services Sociaux (INESSS), Québec, QC, Canada
| | - Xavier Neveu
- Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada; Axe de Recherche: Santé des Populations et Pratiques Optimales en Santé (Traumatologie - Urgence - Soins intensifs), Centre de Recherche du CHU de Québec, Québec, QC, Canada.
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8
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DeMario BS, Stanley SP, Truong EI, Ladhani HA, Brown LR, Ho VP, Kelly ML. Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study. Neurosurgery 2022; 91:e45-e50. [PMID: 35471648 PMCID: PMC9514740 DOI: 10.1227/neu.0000000000002020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/05/2022] [Indexed: 12/21/2022] Open
Abstract
Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.
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Affiliation(s)
| | - Samuel P. Stanley
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Husayn A. Ladhani
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael L. Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
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Farhat I, Moore L, Porgo TV, Assy C, Belcaid A, Berthelot S, Stelfox HT, Gabbe BJ, Lauzier F, Clément J, Turgeon AF. Interhospital Variations in Resource Use Intensity for In-hospital Injury Deaths: A Retrospective Multicenter Cohort Study. Ann Surg 2022; 275:e107-e114. [PMID: 32398484 DOI: 10.1097/sla.0000000000003922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Evaluate interhospital variation in resource use for in-hospital injury deaths. BACKGROUND Significant variation in resource use for end-of-life care has been observed in the US for chronic diseases. However, there is an important knowledge gap on end-of-life resource use for trauma patients. METHODS We conducted a multicenter, retrospective cohort study of injury deaths following hospitalization in any of the 57 trauma centers in a Canadian trauma system (2013-2016). Resource use intensity was measured using activity-based costing (2016 $CAN) according to time of death (72 h, 3-14 d, ≥14 d). We used multilevel log-linear regression to model resource use and estimated interhospital variation using intraclass correlation coefficients (ICC). RESULTS Our study population comprised 2044 injury deaths. Variation in resource use between hospitals was observed for all 3 time frames (ICC = 6.5%, 6.6%, and 5.9% for < 72 h, 3-14 d, and ≥14 d, respectively). Interhospital variation was stronger for allied health services (ICC = 18 to 26%), medical imaging (ICC = 4 to 10%), and the ICU (ICC = 5 to 6%) than other activity centers. We observed stronger interhospital variation for patients < 65 years of age (ICC = 11 to 34%) than those ≥65 (ICC = 5 to 6%) and for traumatic brain injury (ICC = 5 to 13%) than other injuries (ICC = 1 to 8%). CONCLUSIONS We observed variation in resource use intensity for injury deaths across trauma centers. Strongest variation was observed for younger patients and those with traumatic brain injury. Results may reflect variation in level of care decisions and the incidence of withdrawal of life-sustaining therapies.
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Affiliation(s)
- Imen Farhat
- Department of Social and Preventive Medicine, Université Laval, Québec (QC), Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
| | - Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, Québec (QC), Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
| | - Teegwendé Valérie Porgo
- Department of Social and Preventive Medicine, Université Laval, Québec (QC), Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
| | - Coralie Assy
- Department of Social and Preventive Medicine, Université Laval, Québec (QC), Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
| | - Amina Belcaid
- Institut national d'excellence en santé et en services sociaux (INESSS), Québec (QC), Canada
| | - Simon Berthelot
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec (QC), Canada
| | - Henry T Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - François Lauzier
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
- Department of Medicine, Université Laval, Québec (QC), Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec (QC), Canada
| | - Julien Clément
- Institut national d'excellence en santé et en services sociaux (INESSS), Québec (QC), Canada
- Department of Surgery, Université Laval, Québec (QC), Canada
| | - Alexis F Turgeon
- Department of Social and Preventive Medicine, Université Laval, Québec (QC), Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec - Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Québec (QC), Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec (QC), Canada
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10
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Mollayeva T, Mollayeva S, Pacheco N, Colantonio A. Systematic Review of Sex and Gender Effects in Traumatic Brain Injury: Equity in Clinical and Functional Outcomes. Front Neurol 2021; 12:678971. [PMID: 34566834 PMCID: PMC8461184 DOI: 10.3389/fneur.2021.678971] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/09/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Although traumatic brain injury (TBI) is a leading cause of death and disability in male and female patients worldwide, little is known about the effect of sex and gender on TBI outcomes. Objectives: This systematic review summarizes the evidence on the effect of sex and gender on core TBI outcomes. Methods: All English-language studies from six literature databases that addressed core outcomes in adults with TBI and included sex or gender, TBI severity, and age in their analyses were considered eligible. Two reviewers extracted data, and two reviewers assessed study quality using tools recommended by the National Institutes of Health. The results were sorted according to time post-injury, injury severity, gender equity ranking of the study's country of origin, and outcomes studied. The results from the included studies were grouped based on the approach taken in reporting their respective findings. Results and Limitations: Of 172 articles assessed, 58 studies were selected, comprising 1, 265, 955 participants with TBI (67% male across all studies) of all injury severities. All studies were conducted in countries with a very high or high human development index, while the Gender Inequality Index (GII) varied. While the heterogeneity across studies limited any meaningful conclusions with respect to the role of sex and gender, we did observe that as gender equality ranking improved, differences between male and female participants in outcomes would diminish. Inclusion of social equity parameters in the studies was limited. Conclusions and Implications: The non-uniform findings observed bring forth the need to develop and use a comprehensive and consistent methodology in the study of sex and gender post-TBI, incorporating social equity parameters to uncover the potential social underpinnings of gender effects on health and functional outcomes. Systematic Review Registration: CRD42018098697.
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Affiliation(s)
- Tatyana Mollayeva
- KITE Toronto Rehabilitation Institute University Health Network, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,School of Occupational Therapy, Western University, London, ON, Canada
| | - Shirin Mollayeva
- Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada
| | - Nicole Pacheco
- Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,School of Occupational Therapy, Western University, London, ON, Canada
| | - Angela Colantonio
- KITE Toronto Rehabilitation Institute University Health Network, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,Department of Epidemiology, Dalla Lana School of Public Health University of Toronto, Toronto, ON, Canada
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11
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Wijdicks EFM, Hwang DY. Predicting Coma Trajectories: The Impact of Bias and Noise on Shared Decisions. Neurocrit Care 2021; 35:291-296. [PMID: 34426900 PMCID: PMC8382106 DOI: 10.1007/s12028-021-01324-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients’ prior wishes and preexisting medical conditions—but also by what families are told about the patient’s state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
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Affiliation(s)
- Eelco F M Wijdicks
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA. .,Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Y Hwang
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA.,Yale New Haven Hospital, New Haven, CT, USA
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12
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Williamson T, Ryser MD, Ubel PA, Abdelgadir J, Spears CA, Liu B, Komisarow J, Lemmon ME, Elsamadicy A, Lad SP. Withdrawal of Life-supporting Treatment in Severe Traumatic Brain Injury. JAMA Surg 2021; 155:723-731. [PMID: 32584926 DOI: 10.1001/jamasurg.2020.1790] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance There are limited data on which factors affect the critical and complex decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury (sTBI). Objective To determine demographic and clinical factors associated with the decision to withdraw LST in patients with sTBI. Design, Setting, and Participants This retrospective analysis of inpatient data from more than 825 trauma centers across the US in the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2015 included adult patients with sTBI and documentation of a decision regarding withdrawal of LST (WLST). Data analysis was conducted in September 2019. Main Outcomes and Measures Factors associated with WLST in sTBI. Results A total of 37931 patients (9817 women [25.9%]) were included in the multivariable analysis; 7864 (20.7%) had WLST. Black patients (4806 [13.2%]; odds ratio [OR], 0.66; 95% CI, 0.59-0.72; P < .001) and patients of other race (4798 [13.2%]; OR, 0.83; 95% CI, 0.76-0.91; P < .001) were less likely than white patients (26 864 [73.7%]) to have WLST. Patients from hospitals in the Midwest (OR, 1.12; 95% CI, 1.04-1.20; P = .002) or Northeast (OR, 1.23; 95% CI, 1.13-1.34; P < .001) were more likely to have WLST than patients from hospitals in the South. Patients with Medicare (OR, 1.55; 95% CI, 1.43-1.69; P < .001) and self-pay patients (OR, 1.36; 95% CI, 1.25-1.47; P < .001) were more likely to have WLST than patients with private insurance. Older patients and those with lower Glasgow Coma Scale scores, higher Injury Severity Scores, or craniotomy were generally more likely to have WLST. Withdrawal of LST was more likely for patients with functionally dependent health status (OR, 1.30; 95% CI, 1.08-1.58; P = .01), hematoma (OR, 1.19; 95% CI, 1.12-1.27; P < .001), dementia (OR, 1.29; 95% CI, 1.08-1.53; P = .004), and disseminated cancer (OR, 2.82; 95% CI, 2.07-3.82; P < .001) than for patients without these conditions. Conclusions and Relevance Withdrawal of LST is common in sTBI and socioeconomic factors are associated with the decision to withdraw LST. These results highlight the many factors that contribute to decision-making in sTBI and demonstrate that in a complex and variable disease process, variation based on race, payment, and region presents as a potential challenge.
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Affiliation(s)
- Theresa Williamson
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Marc D Ryser
- Duke University Medical Center, Department of Population Health Sciences, Durham, North Carolina
| | - Peter A Ubel
- Duke-Margolis Center for Health Policy, Durham, North Carolina.,The Fuqua School of Business, Duke University, Durham, North Carolina
| | - Jihad Abdelgadir
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Charis A Spears
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Beiyu Liu
- Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Jordan Komisarow
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Monica E Lemmon
- Duke University School of Medicine, Duke University, Durham, North Carolina.,Duke University Medical Center, Department of Pediatrics, Durham, North Carolina
| | - Aladine Elsamadicy
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina
| | - Shivanand P Lad
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
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13
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Kowalski RG, Hammond FM, Weintraub AH, Nakase-Richardson R, Zafonte RD, Whyte J, Giacino JT. Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury. JAMA Neurol 2021; 78:548-557. [PMID: 33646273 DOI: 10.1001/jamaneurol.2021.0084] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness. Objective To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma. Design, Setting, and Participants This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation. Exposures Traumatic brain injury. Main Outcomes and Measures Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings. Results The 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database. Conclusions and Relevance This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.
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Affiliation(s)
- Robert G Kowalski
- Department of Neurology, University of Colorado School of Medicine, Aurora.,Research Department, Craig Hospital, Englewood, Colorado
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis
| | - Alan H Weintraub
- Research Department, Craig Hospital, Englewood, Colorado.,CNS Medical Group, Englewood, Colorado
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Tampa, Florida.,Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital and Harvard Medical School, Boston
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14
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Affiliation(s)
- Jennifer A Kim
- Division of Neurocritical Care, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Division of Neurocritical Care, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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15
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Bonds B, Dhanda A, Wade C, Diaz C, Massetti J, Stein DM. Prognostication of Mortality and Long-Term Functional Outcomes Following Traumatic Brain Injury: Can We Do Better? J Neurotrauma 2021; 38:1168-1176. [PMID: 26230149 DOI: 10.1089/neu.2014.3742] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Accurate prognostication of outcomes following traumatic brain injury (TBI) affects not only the aggressiveness of intervention and therapeutic decision-making but also clinicians' ability to provide reliable expectations. To investigate the relative ability of clinicians to accurately predict a patient's outcomes, compared with point-of-care prognostic models, we surveyed clinical providers of 86 patients with moderate-severe TBI at admission, Day 3, and Day 7 post-injury for a patient's predicted mortality and functional outcome at 6 months. The predicted mortality and functional outcomes were compared with actual occurrence of 14-day mortality and functional outcomes at six months. A prognostic score was then calculated utilizing the Corticoid Randomization After Significant Head Injury (CRASH) and International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) models and categorized as high, intermediate, and low likelihood of mortality or poor functional outcome, and compared with clinical predictions. Overall, clinicians of varying backgrounds showed an accurate prediction of survival (87.2-97.4%) but struggled in prognosticating poor functional outcomes (24.3-36.6%). These values did not statistically improve over 7 days. Stratified CRASH (87.2%) and IMPACT (84.9%) accuracy rates were statistically better than clinical judgment alone in predicting functional outcomes (p < 0.0001). Prognostic models calculated at admission showed to be potentially useful, in conjunction with clinical judgment, in accurately predicting both survival and 6-month functional outcomes.
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Affiliation(s)
- Brandon Bonds
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Amit Dhanda
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Christine Wade
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Carla Diaz
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Jennifer Massetti
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M Stein
- Shock Trauma Anesthesia Research Organized Research Center, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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16
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Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury. Can J Neurol Sci 2021; 48:817-825. [PMID: 33431101 DOI: 10.1017/cjn.2021.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes. METHODS Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer. RESULTS Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition. CONCLUSIONS No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.
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17
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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18
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Hoffman MR, Morris R, Smith T, Denslow S, Schurr M. Early Comfort Care Following Operative Intervention for Traumatic Injury. Am Surg 2020; 86:933-936. [DOI: 10.1177/0003134820940255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Several studies have described the population of adult trauma patients who undergo withdrawal of life-sustaining treatments (WLST); however, no study has looked specifically at trauma patients who undergo WLST following surgery. Methods This was a retrospective chart review of all trauma patients who underwent surgery at our trauma center between January 1 and December 31, 2017. Demographics were collected along with injury patterns and advance directives. Charts of all patients who died or who were discharged to hospice were analyzed to determine whether WLST occurred. Statistics included Fisher’s exact test and Mann-Whitney U test. Results Three thousand and twenty-five adult trauma patients received care and 1495 (49.4%) had operations. Thirty (2.0%) patients underwent WLST, 15 (50.0%) of whom died in the hospital and 15 (50.0%) of whom were discharged to hospice. Twenty-six (86.7%) patients had a palliative care consult and 12 (40.0%) had prior advance directives. The most common injuries were femur fractures and subdural hematomas. Adjusting for age, white race, and age-adjusted CCI, femur fracture patients had, on average, 8.8 more hours between presentation and surgery (95% CI 2.1-15.4, P = .01) and 39 fewer hours between surgery and WLST (95% CI −107–29, P = .26) than traumatic brain injury patients. Discussion The short time between surgery and WLST in this cohort of patients may demonstrate that surgery was not aligned with patients’ goals of care. A patient-centered approach that includes surgeon-driven palliative care discussions may help avoid nonbeneficial surgery in the last few days of life.
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Affiliation(s)
| | - Rachel Morris
- Department of Surgery, Mountain Area Health Education Center (MAHEC), Asheville, NC, USA
| | - Terrie Smith
- Department of Surgery, Mission Hospital, Asheville, NC, USA
| | - Sheri Denslow
- Department of Research, University of North Carolina Health Sciences at MAHEC, Asheville, NC, USA
| | - Michael Schurr
- Department of Surgery, Mountain Area Health Education Center (MAHEC), Asheville, NC, USA
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Stretti F, Klinzing S, Ehlers U, Steiger P, Schuepbach R, Krones T, Brandi G. Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital. Anesth Analg 2019; 127:698-703. [PMID: 29649031 DOI: 10.1213/ane.0000000000003375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.
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Affiliation(s)
- Federica Stretti
- From the Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | | | | | | | | | - Tanja Krones
- Clinical Ethics, University Hospital of Zurich, Zurich, Switzerland
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Patient factors and outcomes associated with the withdrawal or withholding of life-sustaining therapies in mechanically ventilated brain-injured patients: An observational multicentre study. Eur J Anaesthesiol 2019; 35:511-518. [PMID: 29419564 DOI: 10.1097/eja.0000000000000783] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knowledge of the factors associated with the decision to withdraw or withhold life support (WWLS) in brain-injured patients is limited. However, most deaths in these patients may involve such a decision. OBJECTIVES To identify factors associated with the decision to WWLS in brain-injured patients requiring mechanical ventilation who survive the first 24 h in the ICU, and to analyse the outcomes and time to death. DESIGN A retrospective observational multicentre study. SETTINGS Twenty French ICUs in 18 university hospitals. PATIENTS A total of 793 mechanically ventilated brain-injured adult patients. INTERVENTIONS None. MAIN OUTCOME MEASURES Decision to WWLS within 3 months of ICU admission, and death or Glasgow Outcome Scale (GOS) score at day 90. RESULTS A decision to WWLS was made in 171 patients (22%), of whom 89% were dead at day 90. Out of the 247 deaths recorded at day 90, 153 (62%) were observed after a decision to WWLS. The median time between admission and death when a decision to WWLS was made was 10 (5 to 20) days vs. 10 (5 to 26) days when no end-of-life decision was made (P < 0.924). Among the 18 patients with a decision to WWLS who were still alive at day 90, three patients (2%) had a GOS score of 2, nine patients (5%) had a GOS score of 3 and five patients (3%) a GOS score of 4. Older age, presence of one nonreactive and dilated pupil, Glasgow Coma Scale less than 7, barbiturate use, acute respiratory distress syndrome and worsening lesions on computed tomography scans were each independently associated with decisions to WWLS. CONCLUSION Using a nationwide cohort of brain-injured patients, we observed a high proportion of deaths associated with an end-of-life decision. Older age and several disease severity factors were associated with the decision to WWLS.
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Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions. Injury 2019; 50:1064-1067. [PMID: 30745124 DOI: 10.1016/j.injury.2019.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/08/2019] [Accepted: 01/12/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Many injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources. METHODS Trauma Quality Improvement Program (2013-2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student's t tests or Wilcoxon rank sum tests; significance for p < 0.05. RESULTS We identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC. CONCLUSION WLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.
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Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty. Neurocrit Care 2019; 30:33-41. [PMID: 30143963 DOI: 10.1007/s12028-018-0595-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty. METHOD This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached. CONCLUSION In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.
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Spotlight on Neurotrauma Research in Canada's Leading Academic Centers. J Neurotrauma 2018; 35:1986-2004. [PMID: 30074875 DOI: 10.1089/neu.2018.29017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Gerges PRA, Moore L, Léger C, Lauzier F, Shemilt M, Zarychanski R, Scales DC, Burns KEA, Bernard F, Zygun D, Neveu X, Turgeon AF. Intensity of care and withdrawal of life-sustaining therapies in severe traumatic brain injury patients: a post-hoc analysis of a multicentre retrospective cohort study. Can J Anaesth 2018; 65:996-1003. [PMID: 29949093 DOI: 10.1007/s12630-018-1171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/20/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The intensity of care provided to critically ill patients has been shown to be associated with mortality. In patients with traumatic brain injury (TBI), specialized neurocritical care is often required, but whether it affects clinically significant outcomes is unknown. We aimed to determine the association of the intensity of care on mortality and the incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI. METHODS We conducted a post hoc analysis of a multicentre retrospective cohort study of critically ill adult patients with severe TBI. We defined the intensity of care as a daily cumulative sum of interventions during the intensive care unit stay. Our outcome measures were all-cause hospital mortality and the incidence of withdrawal of life-sustaining therapies. RESULTS Seven hundred sixteen severe TBI patients were included in our study. Most were male (77%) with a mean (standard deviation) age of 42 (20.5) yr and a median [interquartile range] Glasgow Coma Scale score of 3 [3-6]. Our results showed an association between the intensity of care and mortality (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.63 to 0.74) and the incidence of withdrawal of life-sustaining therapy (HR, 0.73; 95% CI, 0.67 to 0.79). CONCLUSION In general, more intense care was associated with fewer deaths and a lower incidence of withdrawal of life-sustaining therapies in critically ill patients with severe TBI.
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Affiliation(s)
- Peter R A Gerges
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada.,Department of Social and Preventive Medicine, Université Laval, Québec City, QC, Canada
| | - Caroline Léger
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Michèle Shemilt
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and of Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St-Michaels Hospital, Toronto, ON, Canada
| | - Francis Bernard
- Department of Internal Medicine, Université de Montréal, Montréal, QC, Canada
| | - David Zygun
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Xavier Neveu
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, 1401, 18e rue, local Z-204, Québec City, QC, G1J 1Z4, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada.
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Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, Zarychanski R, Archambault P, Lamontagne F, Léger C, Turgeon AF. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials 2018; 15:398-412. [PMID: 29865897 DOI: 10.1177/1740774518771233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most deaths following severe traumatic brain injury follow decisions to withdraw life-sustaining therapies. However, the incidence of the withdrawal of life-sustaining therapies and its potential impact on research data interpretation have been poorly characterized. The aim of this systematic review was to assess the reporting and the impact of withdrawal of life-sustaining therapies in randomized clinical trials of patients with severe traumatic brain injury. Methods We searched Medline, Embase, Cochrane Central, BIOSIS, and CINAHL databases and references of included trials. All randomized controlled trials published between January 2002 and August 2015 in the six highest impact journals in general medicine, critical care medicine, and neurocritical care (total of 18 journals) were considered for eligibility. Randomized controlled trials were included if they enrolled adult patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) and reported data on mortality. Our primary objective was to assess the proportion of trials reporting the withdrawal of life-sustaining therapies in a publication. Our secondary objectives were to describe the overall mortality rate, the proportion of deaths following the withdrawal of life-sustaining therapies, and to assess the impact of the withdrawal of life-sustaining therapies on trial results. Results From 5987 citations retrieved, we included 41 randomized trials (n = 16,364, ranging from 11 to 10,008 patients). Overall mortality was 23% (range = 3%-57%). Withdrawal of life-sustaining therapies was reported in 20% of trials (8/41, 932 patients in trials) and the crude number of deaths due to the withdrawal of life-sustaining therapies was reported in 17% of trials (7/41, 884 patients in trials). In these trials, 63% of deaths were associated with the withdrawal of life-sustaining therapies (105/168). An analysis carried out by imputing a 4% differential rate in instances of withdrawal of life-sustaining therapies between study groups yielded different results and conclusions in one third of the trials. Conclusion Data on the withdrawal of life-sustaining therapies are incompletely reported in randomized controlled trials of patients with severe traumatic brain injury. Given the high proportion of deaths due to the withdrawal of life-sustaining therapies in severe traumatic brain injury patients, and the potential of this medical decision to influence the results of clinical trials, instances of withdrawal of life-sustaining therapies should be systematically reported in clinical trials in this group of patients.
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Affiliation(s)
- Guillaume Leblanc
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- 3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Lauzier
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,4 Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Véronique Potvin
- 2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- 5 Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick Archambault
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,6 Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - François Lamontagne
- 7 Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada.,8 Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Caroline Léger
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
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Examining racial disparities in the time to withdrawal of life-sustaining treatment in trauma. J Trauma Acute Care Surg 2018; 84:590-597. [DOI: 10.1097/ta.0000000000001775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Moskowitz J, Quinn T, Khan MW, Shutter L, Goldberg R, Col N, Mazor KM, Muehlschlegel S. Should We Use the IMPACT-Model for the Outcome Prognostication of TBI Patients? A Qualitative Study Assessing Physicians' Perceptions. MDM Policy Pract 2018; 3:2381468318757987. [PMID: 30288437 PMCID: PMC6124938 DOI: 10.1177/2381468318757987] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 12/26/2017] [Indexed: 11/15/2022] Open
Abstract
Introduction. Shared Decision-Making may facilitate information exchange, deliberation, and effective decision-making, but no decision aids currently exist for difficult decisions in neurocritical care patients. The International Patient Decision Aid Standards, a framework for the creation of high-quality decision aids (DA), recommends the presentation of numeric outcome and risk estimates. Efforts are underway to create a goals-of-care DA in critically-ill traumatic brain injury (ciTBI) patients. To inform its content, we examined physicians’ perceptions, and use of the IMPACT-model, the most widely validated ciTBI outcome model, and explored physicians’ preferences for communicating prognostic information towards families. Methods. We conducted a qualitative study using semi-structured interviews in 20 attending physicians (neurosurgery,neurocritical care,trauma,palliative care) at 7 U.S. academic medical centers. We used performed qualitative content analysis of transcribed interviews to identify major themes. Results. Only 12 physicians (60%) expressed awareness of the IMPACT-model; two stated that they “barely” knew the model. Seven physicians indicated using the model at least some of the time in clinical practice, although none used it exclusively to derive a patient’s prognosis. Four major themes emerged: the IMPACT-model is intended for research but should not be applied to individual patients; mistrust in the IMPACT-model derivation data; the IMPACT-model is helpful in reducing prognostic variability among physicians; concern that statistical models may mislead families about a patient’s prognosis. Discussion: Our study identified significant variability of the awareness, perception, and use of the IMPACT-model among physicians. While many physicians prefer to avoid conveying numeric prognostic estimates with families using the IMPACT-model, several physicians thought that they “ground” them and reduce prognostic variability among physicians. These findings may factor into the creation and implementation of future ciTBI-related DAs.
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Affiliation(s)
- Jesse Moskowitz
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Thomas Quinn
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Muhammad W Khan
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Lori Shutter
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Robert Goldberg
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Nananda Col
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Kathleen M Mazor
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA (JM, TQ, MWK, SM).,Depts. of Critical Care Medicine & Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA (LS).,Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA (RG).,Shared Decision Making Resources, Georgetown, ME, USA (NC).,Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Internal Medicine, University of Massachusetts Medical School, Worcester, MA, USA (KMM).,Anesthesiology/Critical Care, University of Massachusetts Medical School, Worcester, MA, USA (SM).,Surgery, University of Massachusetts Medical School, Worcester, MA, USA(SM)
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Lesieur O, Genteuil L, Leloup M. A few realistic questions raised by organ retrieval in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S44. [PMID: 29302600 DOI: 10.21037/atm.2017.05.08] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.
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Affiliation(s)
- Olivier Lesieur
- Intensive Care Unit, Saint Louis Hospital, La Rochelle, France
| | - Liliane Genteuil
- Organ Procurement Organization, Bicêtre Hospital, Le Kremlin Bicêtre, France
| | - Maxime Leloup
- Intensive Care Unit, Saint Louis Hospital, La Rochelle, France
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Robertsen A, Førde R, Skaga NO, Helseth E. Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center. Scand J Trauma Resusc Emerg Med 2017; 25:44. [PMID: 28441973 PMCID: PMC5405474 DOI: 10.1186/s13049-017-0385-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/07/2017] [Indexed: 01/08/2023] Open
Abstract
Background Treatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting. Methods A retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs. Results TLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1–652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients’ preferences were found in only 7% of cases. Discussion Clinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting. Conclusion TLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.
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Affiliation(s)
- Annette Robertsen
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Ullevål, P.O.Box 4950, Nydalen, N-0424, Oslo, Norway. .,Department of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, P.O.Box 1130, Blindern, N-0318, Oslo, Norway
| | - Nils Oddvar Skaga
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Ullevål, P.O.Box 4950, Nydalen, N-0424, Oslo, Norway.,Oslo University Hospital Trauma Registry, Oslo, Norway
| | - Eirik Helseth
- Department of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Ullevål, P.O.Box 4950, Nydalen, N-0424, Oslo, Norway
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Turgeon AF, Lauzier F, Zarychanski R, Fergusson DA, Léger C, McIntyre LA, Bernard F, Rigamonti A, Burns K, Griesdale DE, Green R, Scales DC, Meade MO, Savard M, Shemilt M, Paquet J, Gariépy JL, Lavoie A, Reddy K, Jichici D, Pagliarello G, Zygun D, Moore L. Prognostication in critically ill patients with severe traumatic brain injury: the TBI-Prognosis multicentre feasibility study. BMJ Open 2017; 7:e013779. [PMID: 28416497 PMCID: PMC5775467 DOI: 10.1136/bmjopen-2016-013779] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Severe traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury. DESIGN A prospective cohort study. SETTING 9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12 months following injury. OUTCOMES The compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up. RESULTS We successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45 years (IQR 29.0-60.0), a median Injury Severity Score of 38 (IQR 25-50) and a Glasgow Coma Scale of 6 (IQR 3-7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6 months and 2 were at 12 months. CONCLUSIONS In this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.
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Affiliation(s)
- Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Critical Care and of Haematology and Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Unit, Center for Transfusion and Critical Care Research, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Caroline Léger
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Lauralyn A McIntyre
- Clinical Epidemiology Unit, Center for Transfusion and Critical Care Research, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Francis Bernard
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Andrea Rigamonti
- Interdepartmental Division of Critical Care Medicine, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karen Burns
- Interdepartmental Division of Critical Care Medicine, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Green
- Department of Critical Care Medicine, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maureen O Meade
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Martin Savard
- Department of Medicine, Division of Neurology, Université Laval, Québec, Québec, Canada
| | - Michèle Shemilt
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Jérôme Paquet
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec, Québec, Canada
- Department Radiology and Nuclear Medicine, Université Laval, Québec, Québec, Canada
| | - Jean-Luc Gariépy
- Department Radiology and Nuclear Medicine, Université Laval, Québec, Québec, Canada
| | - André Lavoie
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Kesh Reddy
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Draga Jichici
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Giuseppe Pagliarello
- Department of Critical Care Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David Zygun
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Preventive and Social Medicine, Université Laval, Québec, Québec, Canada
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Zeiler FA, Trickey K, Hornby L, Shemie SD, Lo BWY, Teitelbaum J. Mechanism of death after early decompressive craniectomy in traumatic brain injury. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616683208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Decompressive craniectomy in devastating traumatic brain injury is controversial. The impact of decompressive craniectomy on mechanism of death is unclear in the literature to date. Our goal was to determine the mechanism of death between those receiving early decompressive craniectomy and those managed medically. Methods We performed an institutional retrospective review, from June 2003 to June 2013, of adult patients with devastating blunt traumatic brain injury undergoing early decompressive craniectomy who subsequently died. We compared this group to a retrospectively matched group based on: age, pre-hospital KPS, Marshall diffuse computed tomography grades, Injury Severity Scores, and admission laboratory values. Results Forty patients were analyzed; 20 with decompressive craniectomy and 20 without. The two groups were similar based on admission demographics, with the only statistically significant difference being platelet levels. Upon analysis, through both univariate and multivariate regression analysis, the mechanism of death was significantly different (p = 0.003; OR: 0.07 (0.01–0.41) and p = 0.04; OR: 0.08 (0.01–0.87)) with the decompressive craniectomy and non-decompressive craniectomy groups displaying neurological death rates of 10.0% versus 60.0%, respectively, with all other patients in both groups dying secondary to circulatory arrest after withdrawal of life-sustaining therapy. Time to death was significantly longer in the decompressive craniectomy group (2.83 vs. 9.21 days, respectively) (p = 0.01; OR: 0.65 (0.46–0.91). Conclusions Progression to neurological death appears to be more common in those devastating blunt traumatic brain injury patients treated medically compared to those undergoing early decompressive craniectomy. Given the implications of end-of-life care and societal implications, the mechanism of death determination and organ donation should be reported as relevant outcomes in devastating traumatic brain injury studies.
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Affiliation(s)
- FA Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - K Trickey
- Department of Neurosciences, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - L Hornby
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - SD Shemie
- Division of Critical Care, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - BWY Lo
- Department of Neurosciences, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - J Teitelbaum
- Section of Neurocritical Care, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
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Timing of withdrawal of life-sustaining therapies in severe traumatic brain injury: Impact on overall mortality. J Trauma Acute Care Surg 2016; 80:484-91. [PMID: 26595711 DOI: 10.1097/ta.0000000000000922] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality. METHODS This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75th percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013 were involved. The cohort included 17,505 patients with severe isolated TBI. RESULTS One hundred eight centers were classified as early centers. The 75th percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted odds ratio, 0.95; 95% confidence interval, 0.83-1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (AIS) score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions, and signs of compressed or absent basal cisterns. CONCLUSION Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource use. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Mercier E, Boutin A, Shemilt M, Lauzier F, Zarychanski R, Fergusson DA, Moore L, McIntyre LA, Archambault P, Légaré F, Rousseau F, Lamontagne F, Nadeau L, Turgeon AF. Predictive value of neuron-specific enolase for prognosis in patients with moderate or severe traumatic brain injury: a systematic review and meta-analysis. CMAJ Open 2016; 4:E371-E382. [PMID: 27975043 PMCID: PMC5143026 DOI: 10.9778/cmajo.20150061] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prognosis is difficult to establish early after moderate or severe traumatic brain injury despite representing an important concern for patients, families and medical teams. Biomarkers, such as neuron-specific enolase, have been proposed as potential early prognostic indicators. Our objective was to determine the association between neuron-specific enolase and clinical outcomes, and the prognostic value of neuron-specific enolase after a moderate or severe traumatic brain injury. METHODS We searched MEDLINE, Embase, The Cochrane Library and Biosis Previews, and reviewed reference lists of eligible articles to identify studies. We included cohort studies and randomized controlled trials that evaluated the prognostic value of neuron-specific enolase to predict mortality or Glasgow Outcome Scale score in patients with moderate or severe traumatic brain injury. Two reviewers independently collected data. The pooled mean differences were analyzed using random-effects models. We assessed risk of bias using a customized Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Subgroup and sensitivity analyses were performed based on a priori hypotheses. RESULTS We screened 5026 citations from which 30 studies (involving 1321 participants) met our eligibility criteria. We found a significant positive association between neuron-specific enolase serum levels and mortality (10 studies, n = 474; mean difference [MD] 18.46 µg/L, 95% confidence interval [CI] 10.81 to 26.11 µg/L; I2 = 83%) and a Glasgow Outcome Scale ≤ 3 (14 studies, n = 603; MD 17.25 µg/L, 95% CI 11.42 to 23.07 µg/L; I2 = 82%). We were unable to determine a clinical threshold value using the available patient data. INTERPRETATION In patients with moderate or severe traumatic brain injury, increased neuron-specific enolase serum levels are associated with unfavourable outcomes. The optimal neuron-specific enolase threshold value to predict unfavourable prognosis remains unknown and clinical decision-making is currently not recommended until additional studies are made available.
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Affiliation(s)
- Eric Mercier
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Amélie Boutin
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Michèle Shemilt
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - François Lauzier
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Ryan Zarychanski
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Dean A Fergusson
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Lynne Moore
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Lauralyn A McIntyre
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Patrick Archambault
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - France Légaré
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - François Rousseau
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - François Lamontagne
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Linda Nadeau
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
| | - Alexis F Turgeon
- Centre de recherche du CHU de Québec - Université Laval (Mercier, Boutin, Shemilt, Lauzier, Moore, Archambault, Légaré, Turgeon), Population Health and Optimal Health Practices Research Unit; Department of Social and Preventive Medicine (Boutin, Moore); Department of Anesthesiology and Critical Care Medicine (Lauzier, Archambault, Turgeon), Division of Critical Care Medicine; Department of Family Medicine and Emergency Medicine (Archambault, Légaré), Faculty of Medicine (Lauzier); Department of Molecular Biology (Rousseau, Nadeau), Medical Biochemistry and Pathology, Université Laval, Québec City, Que.; Department of Haematology and Medical Oncology (Zarychanski), University of Manitoba, Winnipeg, Man.; Center for Transfusion and Critical Care Research (Fergusson, McIntyre, Turgeon), Clinical Epidemiology Unit, Ottawa Health Research Institute, University of Ottawa; Department of Critical Care Medicine (Fergusson, McIntyre), Ottawa Hospital, University of Ottawa, Ottawa, Ont.; Centre de Recherche Étienne Lebel (Lamontagne), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Que.; Department of Medicine (Lamontagne), Université de Sherbrooke, Sherbrooke, Que
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Lesieur O, Leloup M, Gonzalez F, Mamzer MF. Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units. Ann Intensive Care 2015; 5:56. [PMID: 26092498 PMCID: PMC4486647 DOI: 10.1186/s13613-015-0056-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/28/2015] [Indexed: 01/24/2023] Open
Abstract
Background In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law. Methods The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013. Results During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal). Conclusions More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.
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Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 2015; 41:1572-85. [DOI: 10.1007/s00134-015-3810-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH. METHODS Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis. RESULTS The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160-1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022-1.068, p < 0.001) with the latter also impacting early WOLST decisions. CONCLUSIONS Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.
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Abstract
PURPOSE OF REVIEW Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.
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Hyperosmolar therapy in severe traumatic brain injury: a survey of emergency physicians from a large Canadian province. PLoS One 2014; 9:e95778. [PMID: 24755863 PMCID: PMC3995876 DOI: 10.1371/journal.pone.0095778] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/28/2014] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Worldwide, severe traumatic brain injury is a frequent pathology and is associated with high morbidity and mortality. Mannitol and hypertonic saline are therapeutic options for intracranial hypertension occurring in the acute phase of care. However, current practices of emergency physicians are unknown. METHODS We conducted a self-administered survey of emergency physicians in the province of Québec, Canada, to understand their attitudes surrounding the use of hyperosmolar solutions in patients with severe traumatic brain injury. Using information from a systematic review of hypertonic saline solutions and experts' opinion, we developed a questionnaire following a systematic approach (items generation and reduction). We tested the questionnaire for face and content validity, and test-retest reliability. Physicians were identified through the department head of each eligible level I and II trauma centers. We administered the survey using a web-based interface and planned email reminders. RESULTS We received 210 questionnaires out of 429 potentials respondents (response rate 49%). Most respondents worked in level II trauma centers (69%). Fifty-three percent (53%) of emergency physicians stated using hypertonic saline to treat severe traumatic brain injury. Most reported using hyperosmolar therapy in the presence of severe traumatic brain injury and unilateral reactive mydriasis, midline shift or cistern compression on brain computed tomography. CONCLUSION Hyperosmolar therapy is believed being broadly used by emergency physicians in Quebec following severe traumatic brain injury. Despite the absence of clinical practice guidelines promoting the use of hypertonic saline, a majority of them said to use these solutions in specific clinical situations.
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Rady MY, McGregor JL, Verheijde JL. Transparency and accountability in mass media campaigns about organ donation: a response to Morgan and Feeley. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2013; 16:869-876. [PMID: 23354495 DOI: 10.1007/s11019-013-9466-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We respond to Morgan and Feeley's critique on our article "Mass Media in Organ Donation: Managing Conflicting Messages and Interests." We noted that Morgan and Feeley agree with the position that the primary aims of media campaigns are: "to educate the general public about organ donation process" and "help individuals make informed decisions" about organ donation. For those reasons, the educational messages in media campaigns should not be restricted to "information from pilot work or focus groups" but should include evidence-based facts resulting from a comprehensive literature research. We consider the controversial aspects about organ donation to be relevant, if not necessary, educational materials that must be disclosed in media campaigns to comply with the legal and moral requirements of informed consent. With that perspective in mind, we address the validity of Morgan and Feeley's claim that media campaigns have no need for informing the public about the controversial nature of death determination in organ donation. Scientific evidence has proven that the criteria for death determination are inconsistent with the Uniform Determination of Death Act and therefore potentially harmful to donors. The decision by campaign designers to use the statutory definition of death without disclosing the current controversies surrounding that definition does not contribute to improved informed decision making. We argue that if Morgan and Feeley accept the important role of media campaigns to enhance informed decision making, then critical controversies should be disclosed. In support of that premise, we will outline: (1) the wide-spread scientific challenges to brain death as a concept of death; (2) the influence of the donor registry and team-huddling on the medical care of potential donors; (3) the use of authorization rather than informed consent for donor registration; (4) the contemporary religious controversy; and (5) the effects of training desk clerks as organ requestors at the Department of Motor Vehicles offices. We conclude that organ donation is a medical procedure subject to all the ethical obligations that the medical profession must uphold including that of transparency and truthfulness.
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Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA,
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