When a patient with a severe head injury is in a coma, in intensive care, unconscious and on a ventilator, but not brain dead, when is the time to remove life support? A small study of the plight of people in such situations suggests that doctors and patients’ families might make better decisions if they wait even a few days longer than usual.
Often, a doctor sits down with family members within 72 hours of the patient’s admission to the ICU to discuss the patient’s prognosis and whether they want to keep their loved one alive or remove life support.
Experts say many doctors would describe the outlook as bleak – most likely death or serious disability. Results reported in patients with severe head injuries show that most of the time, the decision is to remove life support. The patient dies.
The researchers behind the new study say their limited data suggests that doctors’ predictions so soon after injury are often wrong.
The study, published Monday in the Journal of Neurotrauma, used a national database including 1,392 head injury patients.
Sifting through the data, they ended up comparing 80 critically injured patients who died after life support was removed, with 80 similar patients whose life support was not removed.
In their analysis, the researchers found that most patients whose vital functions were maintained died in hospital anyway, within about six days. But 42 percent who continued to maintain vital functions recovered sufficiently over the next year to have some degree of independence. A few have even returned to their old lives.
Despite the study’s limitations, “these data are really useful,” said Dr. Walter Koroshetz, director of the National Institute of Neurological Disorders and Stroke, who was not involved in the study. (The institute, part of the federal National Institutes of Health, initially funded the database used by researchers, but it is now funded by grants from multiple sources.) The longer the family waits to make a decision, the better the doctors’ prognosis will be. , he noted.
Uncertainty, however, is omnipresent.
Doctors know, Dr. Koroshetz pointed out, that healing is slow and usually lasts months or even years. But, he said, some patients who needed ventilators and faced a life of extreme disability showed up at the hospital a year later “to discuss it with the nurses.”
“That’s the problem,” he added. “People can recover well.”
But these are rare exceptions. Most of those who survive are left with a permanent disability.
Recovery is not easy. Patients often have to spend months in rehabilitation centers and, for some, the final destination may be a nursing home.
There’s nothing scientific about making a decision within 72 hours, said Dr. Claude Hemphill of the University of California, San Francisco. This deadline has become a convention because, he says, “these people look very sick when they arrive.” As a result, he added, “many doctors felt pressured to make a decision quickly.”
Dr. Hemphill was part of the research group that provided the data, but he did not recruit patients or analyze the data for the study.
Yelena Bodien, a neuroscientist at Massachusetts General Hospital and Spaulding Rehabilitation Hospital, said she and her colleagues were motivated to conduct the study based on their own experiences.
Families who visited patients at the rehabilitation center told her that doctors would say, “Your loved one will never be able to walk, talk or return to work,” she said.
But his colleagues had a different view, telling him: “If we don’t make a decision early, we risk committing these patients to a life they wouldn’t like.” »
She said she saw the problem.
“Doctors are in an extremely difficult situation. Patients are on the brink of life or death with incredibly devastating injuries,” she said. “Doctors are under immense pressure to provide families with an accurate diagnosis. »
Families are asked what kind of life the patient would accept. There may be no easy answer. While healthy people may say that a life with a severe disability would be completely unacceptable, researchers speak of the “disability paradox”: Often, when people become disabled, they report still having a meaningful life.
This is important for counseling families, Dr. Hemphill said. This means that doctors must demonstrate humility not only about the uncertainty of prognosis, but also about the type of life that would be acceptable.
He hopes doctors will take the new study to heart.
“Doctors need to have an open mind,” he said. “Maybe the data-driven truth is a little different than what we were taught in medical school 20 or 30 years ago. »
News Source : www.nytimes.com
Gn Health
