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Goss AL, Hemphill JC, Geocadin RG. ANA Investigates Curing Coma. Ann Neurol 2022; 92:1-2. [PMID: 35599443 DOI: 10.1002/ana.26415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 11/11/2022]
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Claassen J, Akbari Y, Alexander S, Bader MK, Bell K, Bleck TP, Boly M, Brown J, Chou SHY, Diringer MN, Edlow BL, Foreman B, Giacino JT, Gosseries O, Green T, Greer DM, Hanley DF, Hartings JA, Helbok R, Hemphill JC, Hinson HE, Hirsch K, Human T, James ML, Ko N, Kondziella D, Livesay S, Madden LK, Mainali S, Mayer SA, McCredie V, McNett MM, Meyfroidt G, Monti MM, Muehlschlegel S, Murthy S, Nyquist P, Olson DM, Provencio JJ, Rosenthal E, Sampaio Silva G, Sarasso S, Schiff ND, Sharshar T, Shutter L, Stevens RD, Vespa P, Videtta W, Wagner A, Ziai W, Whyte J, Zink E, Suarez JI. Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2021; 35:4-23. [PMID: 34236619 PMCID: PMC8264966 DOI: 10.1007/s12028-021-01260-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023]
Abstract
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University and New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York City, NY, 10032, USA.
| | - Yama Akbari
- Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology and Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Sheila Alexander
- Acute and Tertiary Care, School of Nursing and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas P Bleck
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brandon Foreman
- Departments of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olivia Gosseries
- GIGA Consciousness After Coma Science Group, University of Liege, Liege, Belgium
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - David M Greer
- Department of Neurology, School of Medicine, Boston University, Boston, MA, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jed A Hartings
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H E Hinson
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Theresa Human
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Nerissa Ko
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Kondziella
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA
| | - Lori K Madden
- Center for Nursing Science, University of California, Davis, Sacramento, CA, USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly M McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and University of Leuven, Leuven, Belgium
| | - Martin M Monti
- Departments of Neurosurgery and Psychology, Brain Injury Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care, and Surgery, Medical School, University of Massachusetts, Worcester, MA, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York City, NY, USA
| | - Paul Nyquist
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - DaiWai M Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Javier Provencio
- Departments of Neurology and Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Eric Rosenthal
- Department of Neurology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gisele Sampaio Silva
- Department of Neurology, Albert Einstein Israelite Hospital and Universidade Federal de São Paulo, São Paulo, Brazil
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Nicholas D Schiff
- Department of Neurology and Brain Mind Research Institute, Weill Cornell Medicine, Cornell University, New York City, NY, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Vespa
- Departments of Neurosurgery and Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Walter Videtta
- National Hospital Alejandro Posadas, Buenos Aires, Argentina
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Elizabeth Zink
- Division of Neurosciences Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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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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Linzey JR, Foshee R, Srinivasan S, Adapa AR, Wind ML, Brake C, Daou BJ, Sheehan K, Schermerhorn TC, Jacobs TL, Pandey AS. Neurosurgical patients admitted via the emergency department initiating comfort care measures: a prospective cohort analysis. Acta Neurochir (Wien) 2021; 163:309-315. [PMID: 32820377 DOI: 10.1007/s00701-020-04534-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Given the serious nature of many neurosurgical pathologies, it is common for hospitalized patients to elect comfort care (CC) over aggressive treatment. Few studies have evaluated the incidence and risk factors of CC trends in patients admitted for neurosurgical emergencies. OBJECTIVES To analyze all neurosurgical patients admitted to a tertiary care academic referral center via the emergency department (ED) to determine incidence and characteristics of those who initiated CC measures during their initial hospital admission. METHODS We performed a prospective, cohort analysis of all consecutive adult patients admitted to the neurosurgical service via the ED between October 2018 and May 2019. The primary outcome was the initiation of CC measures during the patient's hospital admission. CC was defined as cessation of life-sustaining measures and a shift in focus to maintaining the comfort and dignity of the patient. RESULTS Of the 428 patients admitted during the 7-month period, 29 (6.8%) initiated CC measures within 4.0 ± 4.0 days of admission. Patients who entered CC were significantly more likely to have a medical history of cerebrovascular disease (58.6% vs. 33.3%, p = 0.006), dementia (17.2% vs. 1.5%, p = 0.0004), or cancer with metastatic disease (24.1% vs. 7.0%, p = 0.001). Patients with a presenting pathology associated with cerebrovascular disease were significantly more likely to initiate CC (62.1% vs. 35.3, p = 0.04). Patients who underwent emergent surgery were significantly more likely to enter CC compared with those who had elective surgery (80.0% vs. 42.7%, p = 0.02). Only 10 of the 29 (34.5%) patients who initiated CC underwent a neurosurgical operation (p = 0.002). Twenty of the 29 (69.0%) patients died within 0.8 ± 0.8 days after the initiation of CC measures. CONCLUSION CC measures were initiated in 6.8% of patients admitted to the neurosurgical service via the ED, with the majority of patients entering CC before an operation and presenting with a cerebrovascular pathology.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Rachel Foshee
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | | | - Arjun R Adapa
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Meghan L Wind
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Carina Brake
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Badih Junior Daou
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Kyle Sheehan
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Thomas C Schermerhorn
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Teresa L Jacobs
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Drive, 3552 Taubman Center, Ann Arbor, MI, 48109-5338, USA.
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Cacic K, Bonomo J. NeuroEthics and End of Life Care. Emerg Med Clin North Am 2020; 39:217-225. [PMID: 33218659 DOI: 10.1016/j.emc.2020.09.013] [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: 10/23/2022]
Abstract
The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.
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Affiliation(s)
- Kelsey Cacic
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Mail Location 0525, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, USA.
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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Provencio JJ, Hemphill JC, Claassen J, Edlow BL, Helbok R, Vespa PM, Diringer MN, Polizzotto L, Shutter L, Suarez JI, Stevens RD, Hanley DF, Akbari Y, Bleck TP, Boly M, Foreman B, Giacino JT, Hartings JA, Human T, Kondziella D, Ling GSF, Mayer SA, McNett M, Menon DK, Meyfroidt G, Monti MM, Park S, Pouratian N, Puybasset L, Rohaut B, Rosenthal ES, Schiff ND, Sharshar T, Wagner A, Whyte J, Olson DM. The Curing Coma Campaign: Framing Initial Scientific Challenges-Proceedings of the First Curing Coma Campaign Scientific Advisory Council Meeting. Neurocrit Care 2020; 33:1-12. [PMID: 32578124 PMCID: PMC7392933 DOI: 10.1007/s12028-020-01028-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Coma and disordered consciousness are common manifestations of acute neurological conditions and are among the most pervasive and challenging aspects of treatment in neurocritical care. Gaps exist in patient assessment, outcome prognostication, and treatment directed specifically at improving consciousness and cognitive recovery. In 2019, the Neurocritical Care Society (NCS) launched the Curing Coma Campaign in order to address the "grand challenge" of improving the management of patients with coma and decreased consciousness. One of the first steps was to bring together a Scientific Advisory Council including coma scientists, neurointensivists, neurorehabilitationists, and implementation experts in order to address the current scientific landscape and begin to develop a framework on how to move forward. This manuscript describes the proceedings of the first Curing Coma Campaign Scientific Advisory Council meeting which occurred in conjunction with the NCS Annual Meeting in October 2019 in Vancouver. Specifically, three major pillars were identified which should be considered: endotyping of coma and disorders of consciousness, biomarkers, and proof-of-concept clinical trials. Each is summarized with regard to current approach, benefits to the patient, family, and clinicians, and next steps. Integration of these three pillars will be essential to the success of the Curing Coma Campaign as will expanding the "curing coma community" to ensure broad participation of clinicians, scientists, and patient advocates with the goal of identifying and implementing treatments to fundamentally improve the outcome of patients.
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Affiliation(s)
- J Javier Provencio
- Department of Neurology and Neuroscience, University of Virginia, Charlottesville, VA, USA
| | - J Claude Hemphill
- Department of Neurology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, Building 1, Room 101, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul M Vespa
- Departments of Neurology and Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University, Barnes-Jewish Hospital, St Louis, MO, USA
| | - Len Polizzotto
- Department of Biomedical Engineering, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh/UPMC Health System, Pittsburgh, PA, USA
| | - Jose I Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
| | - Yama Akbari
- Departments of Neurology, Neurosurgery and the Beckman Laser Institute, University of California-Irvine, Irvine, CA, USA
| | - Thomas P Bleck
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, University of Wisconsin-Madison, Madison, WI, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Theresa Human
- Departments of Neurology and Neurosurgery, Washington University, Barnes-Jewish Hospital, St Louis, MO, USA
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Geoffrey S F Ling
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Martin M Monti
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Nader Pouratian
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Louis Puybasset
- Department of Anesthesiology and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, 75013, Paris, France
| | - Benjamin Rohaut
- Department of Neurology, Neuro-ICU, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicholas D Schiff
- Departments of Neurology, Neuroscience, and Medical Ethics, Weill Cornell Medicine, New York, NY, USA
| | - Tarek Sharshar
- Neuro-anesthesiology and Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
- Experimental Neuropathology, Infection and Epidemiology Department, Institut Pasteur, Paris, France
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, Department of Neuroscience, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - DaiWai M Olson
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
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7
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Linzey JR, Burke JF, Nadel JL, Williamson CA, Savastano LE, Wilkinson DA, Pandey AS. Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures. J Neurosurg 2019; 131:1725-1733. [PMID: 30554183 DOI: 10.3171/2018.7.jns181226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/31/2018] [Indexed: 01/05/2023]
Abstract
OBJECTIVE It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery. METHODS This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively. RESULTS Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70-79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00. CONCLUSIONS Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.
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Affiliation(s)
| | | | | | - Craig A Williamson
- Departments of2Neurology and
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Luis E Savastano
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - D Andrew Wilkinson
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Aditya S Pandey
- 3Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
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8
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Boyer F, Audibert G, Baumann C, Colnat-Coulbois S, Pinelli C, Claudot F, Baumann A. [Decision-making regarding treatment limitation after severe traumatic brain injury: A survey of French neurosurgeons]. Neurochirurgie 2018; 64:401-409. [PMID: 30424955 DOI: 10.1016/j.neuchi.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 06/11/2018] [Accepted: 07/27/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND/INTRODUCTION In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury. AIM OF THE STUDY The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons. METHODS A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016. RESULTS Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age. CONCLUSIONS Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making.
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Affiliation(s)
- F Boyer
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France
| | - G Audibert
- Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France; Service d'anesthésie réanimation chirurgicale, CHRU de Nancy, hôpital central, 54000 Nancy, France
| | - C Baumann
- UMDS, CHRU de Nancy-hôpitaux de Brabois, plateforme d'aide à la recherche clinique (PARC), 54505 Vandœuvre-lès-Nancy, France
| | - S Colnat-Coulbois
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France
| | - C Pinelli
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France
| | - F Claudot
- UMDS, CHRU de Nancy-hôpitaux de Brabois, plateforme d'aide à la recherche clinique (PARC), 54505 Vandœuvre-lès-Nancy, France; EA4360 APEMAC, université de Lorraine, 54000 Nancy, France
| | - A Baumann
- EA4360 APEMAC, université de Lorraine, 54000 Nancy, France; Département d'anesthésie réanimation, hôpitaux universitaires Paris-Sud, hôpital Bicêtre, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.
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