Is life support removed too soon in severe TBI?

Some patients with severe traumatic brain injury (TBI) who died when life support was removed may have survived and at least partially regained their independence had life-sustaining treatment been continued. a new study shows.

Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) suggest that delaying the decision to withdraw life support may be beneficial for some patients.

“We found that a significant proportion of patients who died after life support was removed would have died anyway, even if life support had been continued,” study investigators said. said Dr. Elena Bodien of the Department of Neurology and Physical Therapy at Massachusetts General Hospital. Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School in Boston said. Medscape Medical News.

“However, a remarkable and unexpected finding was that, of those who would have survived had life support not been removed, as many as 40% of patients were predicted to regain some degree of independence by six months post-injury. “That was the case,” she added.

However, the researchers noted that the results do not apply to brain death, as none of the patients who died in the study were determined to be brain dead.

The research is Published online on may 13th Neurotrauma Journal.

Predicting Outcomes: The Challenge

Predicting outcomes after severe traumatic brain injury can be difficult, and there are currently no medical guidelines or precise algorithms to determine which patients are likely to recover, researchers note. did. However, they added that families are often asked to make decisions about withdrawing life support within 72 hours of a severe TBI.

The study involved more than 1,300 patients with severe traumatic brain injury from 18 trauma centers across the United States. The researchers created a mathematical model to estimate the likelihood of at least partial functional recovery six months after injury. We then developed a propensity score-matched cohort of severe TBI patients with and without withdrawal of life-sustaining treatment in the intensive care unit.

To optimize matching with unequal distribution of propensity scores, the life support cohort was divided into stages based on propensity to withdraw (stage 1, 0%–11%; stage 2, 11% ~27%, and stage 3, 27%-70%).

A total of 56 patients were not withdrawn from life support. At 6 months, 31 (55%) had died, while 25 (45%) were alive. Survival rates for Tiers 1, 2, and 3 were 88%, 54%, and 24%, respectively.

A “cautious approach” is justified

Glasgow Outcome Scale Extended (GOSE) data at 6 months showed 10 of 15 (67%) people on life support in Tier 1, 19 of 25 (76%) in Tier 2, and 10 of 40 people on life support in Tier 2. It was available for 27 people (68%). ) Tier 3.

Recovery of at least partial independence (GOSE ≥ 4) occurred in more than 40% of the total sample and Tier 1 and 2 survivors.

For Tier 1 and Tier 2 combined, four patients recovered to their pre-injury baseline level of function (GOSE 8). Her eight patients in Tier 1 and Tier 2 have recovered to her GOSE 3. This represents a lower severity disability category that includes a wide range of functioning and may also include patients who are independent in activities of daily living.

The researchers noted that the findings support recent calls for a cautious approach to early decisions about withdrawing life support.

However, death or severe disability is a common outcome, particularly for Tier 3 patients, who have the highest propensity for withdrawal of life support among matched cohorts, and “providers are not able to survive or remain independent.” “It has shown that it is often accurate in identifying certain patients,” Professor Bodien said. 6 months is unlikely. ”

“These are patients who are typically taken off life support because there is no hope of recovery, and our results suggest that this was probably not the case,” Bodien said. “We hope that our findings will cause clinicians to pause, talk to families, and present that as an option before recommending something as irreversible and serious as withdrawing life support.”

“More research is needed in this area to improve the accuracy of predicting how patients with particularly severe TBI will recover, but at the very least, studies like this one can help clinicians We hope that people will be cautious when considering the withdrawal of life's support for patients with severe traumatic brain injury,'' she added.

Involvement of external experts

Reached for comment, Tatiana Moraeva, MD, Canada Research Chair in Neurological Disorders and Brain Health and deputy director of the Acquired Brain Injury Laboratory at the University of Toronto, said the study was designed to “highlight new directions for scientific research. It is important.” regarding some issues.

These include “the effectiveness of consent in relation to acceptance and refusal of life-sustaining treatment, the ability of family members and surrogates to make decisions on behalf of patients in times of great suffering, and confidence in clinical judgment and differential diagnosis.” ” is included. “Given the neurodiversity of the process,” said Moraeva, who was not involved in the study. Medscape Medical News.

“Our understanding of recovery after acute brain injury has long been mired in nihilism and self-fulfilling prophecies,” said Ariane Lewis, MD, director of neurocritical care at New York University Langone Medical Center in New York, New York. It has been recognized that poor outcomes are expected, leading to premature discontinuation of life-sustaining treatment and death.

“Factors associated with the decision to discontinue life-sustaining treatment, such as previously stated beliefs about quality of life, previous dependencies, religion, and other medical issues, were not incorporated into this study and its content. “It is important to note that the proportion of discussions regarding treatment goals is unknown,” said Lewis, who was not involved in the study.

“Still, it is important to understand that recovery after acute brain injury can take many months,” she added. “People should discuss these wishes with family and friends to ensure that they are honored in the unfortunate event that acute brain injury results in loss of decision-making capacity.”

David Greer, MD, professor and chair of the Department of Neurology at Boston University School of Medicine in Massachusetts, echoed this sentiment. Medscape Medical News He said this was a “very important” study and would be carried out in a “very responsible and sensitive manner”.

Professor Greer said the study's results “confirm what we have long feared: that there is a self-fulfilling prophecy bias that leads to early discontinuation of life-sustaining treatment in patients with a good chance of a positive outcome.” It's a thing,” he said.

“I think this sows the seeds for future prospective studies to assess this in a way that allows patients to live longer and find more reliable signs that they may recover in a delayed manner.” “It's certainly very interesting news.” Greer.

Developing essential evidence-based predictive tools

Shaheen Rakan, MD, a neurologist and researcher based in Miami, Florida, was also contacted for comment. Medscape Medical News The current state of neuroprognosis “often leaves us in the dark, relying on fragmented data and uncertain outcomes to guide these important decisions. This uncertainty can lead to premature discontinuation of life-sustaining treatments.” , some patients may miss out on a meaningful recovery.”

Advances in comprehensive, evidence-based predictive tools are essential, he added.

“By incorporating a wide range of clinical, demographic, and biometric data, these models can improve the accuracy of their predictions. Investment in research and technology is essential to developing these tools. It should be readily available and integrated into standard clinical practice,” Lacan said.

He called on the medical community, researchers, policy makers and society at large to join this effort.

“Moving forward from the shadow of uncertainty and embracing a future where every decision is based on the best evidence, every family is supported with compassion and clarity, and every patient is given the fairest chance of recovery.” Let's do it,'' he said. . “Together, we can move neuroprecognition out of the dark ages and into an age of enlightenment and hope.”

This research was supported by contributions from the National Institute of Neurological Disorders and Stroke, the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), the Office of the Director of the National Institutes of Health (NIH), the James S. McDonnell Foundation, and the Chen Institute MGH Investigators. Supported by grants. Awarded by the U.S. Department of Defense (DoD) and the U.S. Department of Energy. The authors and Mollayeva, Lewis, Greer, and Lakhan have no relevant disclosures.