by Pratt, Alexandra K.;
Chang, Jason J.; Sederstrom, Nneka O.
Objectives: To
describe the sources of uncertainty in prognosticating devastating brain
injury, the role of the intensivist in prognostication, and ethical
considerations in prognosticating devastating brain injury in the ICU.
Data Sources: A
PubMed literature review was performed.
Study Selection:
Articles relevant to prognosis in intracerebral hemorrhage, acute ischemic
stroke, traumatic brain injury, subarachnoid hemorrhage, and postcardiac arrest
anoxic encephalopathy were selected.
Data Extraction: Data
regarding definition and prognosis of devastating brain injury were extracted.
Themes related to how clinicians perform prognostication and their accuracy
were reviewed and extracted.
Data Synthesis:
Although there are differences in pathophysiology and therefore prognosis in
the various etiologies of devastating brain injury, some common themes emerge.
Physicians tend to have fairly good prognostic accuracy, especially in severe
cases with poor prognosis. Full supportive care is recommended for at least 72
hours from initial presentation to maximize the potential for recovery and
minimize secondary injury. However, physician approaches to the timing of and
recommendations for withdrawal of life-sustaining therapy have a significant
impact on mortality from devastating brain injury.
Conclusions:
Intensivists should consider the modern literature describing prognosis for
devastating brain injury and provide appropriate time for patient recovery and
for discussions with the patient’s surrogates. Surrogates wish to have a
prognosis enumerated even when uncertainty exists. These discussions must be
handled with care and include admission of uncertainty when it exists. Respect
for patient autonomy remains paramount, although physicians are not required to
provide inappropriate medical therapies.
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