Ethical issues in neurocritical care

Medicine has always tried to push the limits of life. The technological and scientific progress made in resuscitation now makes it possible to keep patients who are more and more severely affected alive, by compensating for organ failure. The management of the brain-damaged patient poses specific ethical problems in intensive care. Most in-hospital deaths of patients with severe acute brain injury occur after a decision to withhold or withdraw life-sustaining treatments. In these patients, a problem is the difficulty in predicting outcome at an early stage. Our reasoning in the management of brain-damaged patients in the intensive care is based on the four main principles of medical ethics: autonomy, beneficence, non-maleficence and distributive justice. In the case of a patient suffering from cerebral palsy, consent is most often impossible to obtain. The respect of this autonomy, can be done by means of advance directives or testimonies of the support person and family. Non-malficence in the resuscitated brain-damaged patient consists of avoiding unreasonable obstinacy. Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient's medical condition. A determination of medical futility can be made either in the presence of a vanishingly small probability of physiological effect or an exceedingly poor quality of outcome. However, a distinction must be made between loss of autonomy and unreasonable obstinacy. French law specifies that the physician must use collegial procedure in situations that may concern a brain-damaged patient. In terms of ethical decision-making, the concept of "window of opportunity" is often mentioned. The temporal approach taken is the guarantee of an absence of "a rush". It is important for the health care team and the family to share the progress of the treatment so that everyone understands the evolution of what is happening and the risks taken for the patient. The resuscitation of the brain-damaged patient poses specific and difficult ethical problems. One of the challenges is to be able to assume our decisions, understand them and defend them. It is also to maintain the coherence of our actions and the cohesion of our teams necessary for the good care of our patients.

Severe stroke: which medicine for which results?

In face of any severe stroke, the questions for health professionals in charge of the patient are: will the handicap be acceptable for the patient? But can we predict an acceptable handicap for the patient? For his family? When we know that the cognitive disorders, consequences of severe stroke often modify, in a major way, the behaviour of these patients? Given these difficulties for estimate vital and functional prognosis and even more the quality of life of patients with severe stroke, collective reflexions between physicians and nurses are essential, reflexions taking into account preferences and values of patients. Use of resuscitation resources for severe stroke patients implies to offer them the best rehabilitation. So, questions about health pathways for severe stroke are essential: which structures for these patients, which technologies, which medical, medico-social and social supports, which human accompaniment the society can propose to the patients and to their family, so that they have an acceptable quality of life.