These findings are certainly cause for careful consideration prior to withdrawal of care in any acute care setting.
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ACEP News: Vol 30 – No 10 – October 2011
“We still do not know one thousandth of one percent of what nature has revealed to us.”
– Albert Einstein
“I was gratified to be able to answer promptly. I said I don’t know.”
– Mark Twain
Traumatic brain injury is a common and potentially devastating diagnosis. Traumatic brain injury is one of the leading causes of death and disability in the United States (Am. J. Prev. Med. 2011;41:61-7).
This recent study by Dr. Alexis F. Turgeon and colleagues (see story on p. 1) studied 720 patients with traumatic brain injury and demonstrated significant variation in mortality.
The authors cite “limited accuracy of current prognostic indicators,” which is no surprise to anyone who has been practicing medicine for any length of time. Doctors are not good at prognosis. Patients frequently want to know the answers to prognostic questions ranging from the minimal to the monumental: “Will it hurt?” “How long will I be sick?” “How long should I be off work?” “When can I go back to football?” “Is he going to be okay?” “How much time do I have left?” “What will happen to our Dad if we withdraw life-sustaining care?”
We pride ourselves on knowing the answers to questions. In college, we learned the answers to physics and chemistry questions. In medical school, we learned the answers to the USMLE questions. In residency, we learned the answers to ABEM questions. In practice, however, is where the rubber meets the road. Unfortunately all those “answers” we learned in college, medical school, and residency do not answer all questions that our patients pose to us.
Sometimes we simply estimate the answers to questions of little import. For a patient with a shoulder strain, perhaps it is not critical whether they avoid heavy lifting for 3 days or 7 days. For a patient with a fractured femur, we can estimate based on experience about return to normal function.
However, for decisions with life and death ramifications, such as withdrawal of life-sustaining care, such estimates are ultimately much more important. Our limitations in prognostication carry potentially greater ramifications.
Estimating prognosis after critical injuries or illnesses is challenging within the first 24 hours. Even the best emergency physicians are unable to accurately predict neurologic outcome.
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.
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