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

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)

We recommend determining prognosis from repeated examinations over time to establish greater confidence and accuracy. (Moderate, Strong)

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)

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)

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)