Recent research has identified several factors associated with poor outcomes, including extracranial injury (Neurosurgery 2001 Sept. 5; doi: 10.1227/NEU.0b013e318235d640; J. Head Trauma Rehabil. 2011 Sept. 2; doi: 10.1097/HTR.0b013e3182248344), plasma biomarkers (J. Neurotrauma 2011 Sept. 2; doi: 10.1089/neu.2011.1789; Pediatr. Crit. Care Med. 2011;12:319-24), lack of early rehabilitation (J. Neurotrauma 2011 Aug. 24; doi: 10.1089/neu.2011.1811), cerebral hypoperfusion (J Trauma. 2011;71:364-74), age, and level of consciousness (J. Neurotrauma 2011 July 25; doi: 10.1089/neu.2011.2034).

It is clear from decades of studying outcomes in traumatic brain injury that there is no single gold standard that can be used to accurately predict neurologic outcome during the acute phase after injury.

In this study by Dr. Turgeon and colleagues, 70% of deaths occurred after withdrawal of life-sustaining therapy. The question that is not answered by this study is whether these withdrawals of therapy were appropriate or not. The mere fact that critical patients died after withdrawal of life-sustaining therapy does not mean the withdrawal was inappropriate. It is likely that in most or all of these cases, withdrawal of care merely hastened the inevitable terminal outcome.

What does this mean for emergency physicians? Does this mean we should never withdraw care for ED patients? These findings are certainly cause for careful consideration prior to withdrawal of care in any acute care setting. Recognition of our limitations is essential – we have not identified any single test or measurement that will accurately predict neurologic outcomes, and we cannot predict the future for an individual patient in the acute phase. Appropriate actions for emergency physicians include accurate delivery of information to families and discussions about goals of therapy, potential outcomes, and any previously stated patient wishes. Establishing a collaborative shared model for decision making with health care providers and families must be our priority.

Dr. Marco is a professor and program director, emergency medicine residency, and director of medical ethics curriculum at the University of Toledo.