Predicting decline and survival in severe acute brain injury: the fourth trajectory
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3904 (Published 06 August 2015) Cite this as: BMJ 2015;351:h3904
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This article on end of life care focuses on stroke and brain injury. Everyone agrees that patients and family and friends need support and empathic educational and realistic comunication. Every patient in danger of death requires the very best and balanced health care. We cannot predict the future. We can quote statistics and usual outcomes and desirable usual interventions such as peg feeding and parenteral hydration and ventilation and management of intercurrent infections etc. Every patient deserves their own best chance of survival.
Nothing new here. What is new in this "fourth way" described in this article is the menu of possible withdrawals of life sustaining treatments. Artificial nutrition and hydration are treatment as usual for many non-dying patients, as are antibiotics for RTIs. People with chronic neurological conditions may need long term artificial hydration and nutrition. These are not optional extras but necesssary and ordinary care for any patient. Withdrawing regular treatments is withdrawal of care, no matter what euphemism you use. To use terminology to categorise treatments as "comfort treatment" as opposed to "active treatment" is an attempt to confuse people and obfuscate what is actually happening. Ethics committes and medical teams and legal teams have dificult decisions to make in chronic or acute disability cases where function will not (more than likely return), but the bottom line in medicine always has been to protect life with the use of regular non-extraordinary measures, and with extraordinary measures if the patient and decision makers agree to it. To not do so would expose a doctor to litigation. The issue at stake here is the value and respect for human life no matter how damaged it is and will be. It hinges on the morality of respecting and sustaining human life as best one can, and allowing death to occur when life ebbs away. To hasten death by withdrawing necessary and ordinary care is euthanasia. This was exemplified by The Liverpool Care Pathway.
Competing interests: No competing interests
Re: Predicting decline and survival in severe acute brain injury: the fourth trajectory
The authors are to be commended for their balanced discussion regarding the communication of health trajectories following severe acute brain injury.
However, they omit vital detail regarding an essential component of the early communication and decision making processes, namely the concept that a comparatively short window of opportunity (days) often exists, during which, withdrawal of active supportive care, usually mechanical ventilation and / or vasoactive agents, results in a rapid death. Such an approach may be viewed by all concerned as humane and in accordance with the beliefs of the patient.
Living with severe neurodisability with grossly diminished conciousness, awareness and autonomy may be considered as a fate worse than death, both by the patient (pre-injury) and their friends and family. The decision to opt for heroic procedures or an extended period of maximal intervention can result in a protracted death based solely upon the unlikely event of a significant or even miraculous recovery. The negative consequences of such a death for the patient and their friends and family can be considerable.
As clinicians, our ability to provide an accurate prognosis of the extent of long term neurodisability following severe acute brain injury is limited, most especially in the first few days. However, we should not avoid early and open discussions about the consequences of postponing decisions merely to reduce our uncertainty.
Competing interests: No competing interests