Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group

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Journal of neurotrauma


Best practice guidelines have advanced severe traumatic brain injury (TBI) care, however, little currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, acceptability of neurological outcomes as well as putative means of improving decisions which may limit care. 97.6% of the 42 SIBICC panelists completed the survey. Responses were highly variable to most questions. Overall panelists reported infrequent use of prognostic calculators and observing variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a 'nihilism guard'. Over 50% of panelists felt that if it was certain to be enduring, a vegetative state or lower severe disability would justify a withdrawal of care decision while 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, a 64-69% chance of a poor outcome on average was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes which might prompt consideration of care withdrawal, however imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care limiting decisions.

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ePub ahead of print