After traumatic brain injury, life-sustaining decisions may take more time

DDeciding whether to withdraw life support after a severe traumatic brain injury is extremely difficult. Loved ones are faced with balancing their hopes for recovery and the desire not to prolong suffering, and physician insight is essential.

With the support of critical care physicians, most decisions about whether to discontinue life support are made within 72 hours of hospital admission. But a new article appeared on Monday in the Journal of Neurotrauma suggests that waiting a little longer – and collecting more data – may be helpful.

“There is a lot of uncertainty in the clinical world about which patients will recover, to what extent they will recover, and when they will recover,” said corresponding author Yelena Bodien, assistant professor of neurology. at Massachusetts General Hospital and in physical medicine and rehabilitation at Spaulding Rehabilitation Hospital.

To learn more about these possible recovery pathways, Bodien and her colleagues enrolled nearly 3,100 traumatic brain injury patients at 18 trauma centers across the US between 2014 and 2021. The patients were enrolled within 24 hours of their injuries, and the researchers followed about half of the patients. them for a year. Of these patients, 90 died when life support was removed. The researchers matched them – across clinical, demographic and socio-economic factors – to 90 similar patients in the study group whose life support had not been withdrawn, to compare outcomes.

In many cases, patients kept on ventilators died, especially those who were older and had more serious injuries. But almost 30% of matched patients made a meaningful recovery within six months and returned to at least partial independence. This could mean that they live with a disability that still allows them to participate in certain life roles that they previously occupied; others, with less serious injuries, were able to return to normal life. Among younger patients with fewer health problems and less serious injuries, at least 50% have regained some independence.

“Although an injury can look quite devastating hours or a few days after it occurs, in many cases we have some evidence to suggest that even with the most devastating injuries, people can experience a recovery months or years later that is is meaningful.” Bodien said.

This doesn’t mean the patients whose life support was withdrawn would survive, Bodien said — nearly 60% of them would likely have died anyway. And the study should not be applied to individual cases, Bodien warned: the authors are not suggesting that life support should always be continued.

“What we don’t want is for families to prolong suffering because they’re afraid they’re missing out,” said Theresa Williamson, co-author of the study and assistant professor of neurosurgery at Massachusetts General Hospital. teaching faculty at the Harvard Center for Bioethics. “I imagine if I was a family member reading this, I would think, ‘Oh my goodness, did I do something wrong? Did I miss it?’ And I think the answer is: probably not.”

But Bodien said these results call for more collaboration between critical care physicians and rehabilitation professionals. “Intensive care physicians don’t have the ability to follow their patients long-term,” says Bodien, who works in both acute care and rehabilitation, where she often sees patients recover for weeks or months after devastating injuries. “They see a very sick patient with a devastating injury, and they can’t even imagine what it could look like in the long term.”

On the other hand, Bodien acknowledges that rehabilitation physicians may not be as well-versed in understanding the severity of an injury as their acute care counterparts. “[We] We need to work together across disciplines to truly understand the long-term trajectory of recovery,” she said.

Fundamentally, the findings highlight the uncertainty associated with prognosis after severe brain injury. “Rather than making decisions very early, maybe we should continue the conversation a little longer and look at the trends so we can better understand how people are doing, rather than being a bit nihilistic about it,” Williamson said.

James Sulzer, a professor in the department of physical medicine and rehabilitation at Case Western Reserve University who was not involved in the study, agrees that waiting some time after a traumatic brain injury can be helpful. “We can’t really predict what’s going to happen based on the first few days after an injury,” he said. “We don’t know enough about how damage to the brain affects its function. We don’t know enough about how damage to the brain affects recovery.”

Until there are better ways to quickly create an accurate forecast, taking more time may be essential. Not only could it help doctors make more informed decisions, it would also give loved ones the opportunity to think more clearly about the best choice to make, Sulzer said. When his young daughter suffered a serious brain injury, he recalled, he was not in a psychological position to make decisions for days.

“The overall message,” Bodien said, is “a very cautious approach to withdrawing life-prolonging treatment, and perhaps giving people a few extra days to demonstrate their potential for recovery.”