Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

Publication Date: April 1, 2015

Recommendations

Definition and Prognostication

We recommend defining devastating brain injury (DBI) as:
  • Neurological injury where there is an immediate threat to life from a neurologic cause
  • Severe neurological insult where early limitation of therapy (defined as treatment of disease, is being considered in favor of an emphasis on care, e.g., the provision of comfort measures).
(, Strong)
(expert opinion)
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We recommend determining prognosis from repeated examinations over time to establish greater confidence and accuracy. (Moderate, Strong)
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We recommend applying these guidelines in the early stages of DBI treatment in order to maintain physiologic stability, even when early limitation of aggressive care is being considered. Such early implementation prevents unwarranted deterioration and allows sufficient opportunity for prognostic evaluation, care planning, and consideration of organ donation. (Moderate, Strong)
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We recommend using a 72-h observation period to determine clinical response and delaying decisions regarding withdrawal of life-sustaining treatment in the interim. (Moderate, Strong)
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We recommend that clinicians consider all known prognostic variables in determining risk of death and that prognostication be based on individualized assessment of risk factors rather than on clinical scoring systems. (Moderate, Strong)
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Psychosocial Management

We recommend that clinicians anticipate family needs for information, allow proximity to the patient, provide emotional support, and assess for unmet additional needs specific to the individual(s). (Low, Strong)
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We recommend early, frequent, and consistent multidisciplinary communication regarding patient condition. (Low, Strong)
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We recommend that clinicians provide clear information regarding condition and prognosis and include a discussion of prognostic uncertainty if appropriate. (Low, Strong)
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Consider using a family support specialist to improve ongoing education and support. (Low, Weak)
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Encourage proximity and involvement in care when desired by the family. (Low, Strong)
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We recommend early identification of the healthcare proxy and their preferred decision-making approach. (Low, Strong)
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We recommend prioritization of information sharing with the healthcare proxy, as well as staggering information delivery when possible to minimize cognitive and emotional overload. (Low, Strong)
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We recommend focusing clinical decision-making on the patient’s preferences, goals, and values. (Low, Strong)
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We recommend assuring proxies that compassionate and quality care will continue regardless of withdrawal decisions. (Low, Strong)
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We recommend early involvement of resources such as social services, religious leaders, and palliative care. (Low, Strong)
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Ethics

When resources allow, all DBI patients without a known pre-existing objection to treatment should be aggressively resuscitated for an initial period (see above) to maximize the likelihood of potential neurologic recovery or the opportunity for organ donation. (, Strong)
(expert opinion)
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The consent for initial resuscitation ought to be assumed unless there is a pre-existing known objection and should not be dependent on organ donor status. (, Strong)
(expert opinion)
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We recommend that notification of DBI patient donor status during the resuscitative period, if done, should not alter resuscitative efforts. (, Strong)
(expert opinion)
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We recommend that the resuscitation of the DBI patient should not be dependent on the possibility of organ donation. (, Strong)
(expert opinion)
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We recommend that if resuscitative efforts are futile and no option for organ donation exists, there is no prima facie obligation to continue to resuscitate the DBI patient. (, Strong)
(expert opinion)
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We recommend the use of appropriate analgesic and sedative medication in DBI patients to relieve undue suffering regardless of secondary circumstances, such as futility, organ donation, and need for prognostication. (, Strong)
(expert opinion)
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We recommend that palliative sedation should not exclude the possibility of organ donation. (, Strong)
(expert opinion)
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In the absence of evidence to the contrary, we recommend that DBI patients should be resuscitated in an attempt to respect autonomy. (, Strong)
(expert opinion)
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We recommend that clinicians respect legitimate directives to restrict resuscitative efforts in DBI patients. (, Strong)
(expert opinion)
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Recommendation Grading

Disclaimer

Overview

Title

Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

Authoring Organization

Publication Month/Year

April 1, 2015

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

It provides recommendation on management of devastating brain injury duringthe first 72-h post-injury based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference.

Target Patient Population

Patients with devastating brain injury

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D003422 - Critical Care, D001930 - Brain Injuries, D009462 - Neurology

Keywords

Brain injury, devastating brain injury

Source Citation

DOI 10.1007/s12028-015-0137-6