Withdrawing Life Sustaining Treatment – Early Withdrawal of Life Sustaining Treatment in Severe Traumatic Brain Injuries, by Bernard W. Freedman JD, MPH

CDC Statistics Traumatic Brain Injuries

On August 29, 2011 the Canadian Medical Association published the findings of a multicenter cohort study evaluating the withdrawal of life-sustaining treatment for patients who had suffered a traumatic brain injury. This study is of particular interest because by the nature of the injury  patients cannot make decisions for themselves and generally such decisions in patients in end-of-life care have a variety of comorbidities which make an evaluation of the efficacy of the decisions to withdraw life sustaining care difficult.

720 patients were evaluated from six different major medical centers. Of the 720, 228 patients did not survive.  160 patients had life sustaining treatment withdrawn in the first three days of hospitalization.

In approximately 50% of the patients, deaths occurred within the first three days of admittance to the ICU. Most of the deaths were associated with withdrawing life-sustaining care (64%) yet the proportion varied significantly across the six medical centers, from 30.4% to 92.9%

Considering deaths due to withdrawal of life-sustaining care within the first three hospital days, an overall average of 45.6% occurred. However examining the outcomes from the six medical centers, the range of deaths due to withdrawal of life-sustaining care ranged from 22.2% to 59.1%.

According to the “medical teams” and who participated in the care, the reason given for withdrawing life-sustaining care was:

1.     Poor chance of survival. (54.4%).

2.     Prognosis was incompatible with the patient’s wishes. (33.8%)

3.     A poor long-term neurologic prognosis. (28.5%)

These stated justifications are suspect because of the rapidity that decisions to withdraw life-sustaining care were arrived at. As the authors of this study indicate:

 “in this specific population of patients, the decision to withdraw life-sustaining therapy made by patients’ relatives and medical teams is mainly based on prognostic information. Our findings are particularly concerning because many decisions to withdraw life-sustaining therapy were made early in our study: 64% of the patients who died within three days of admission to an ICU had life-sustaining therapy withdrawn. In some instances, this may be too early for accurate neuroprognostication.”

1. “Poor chance of survival. (54.4%)”

     Means: She is probably going to die soon anyway, so let’s not wait and see, waste our time and costs, and extubate now.

This is a, ” She is probably going to die soon so let’s not wait and see  and waste time and costs and extubate now” type of argument.

Yet, if the patient is going to die “soon” anyway, why not let her die without withdrawing the ventilator – for example. Waiting can only help us have a clearer picture of the degree of the damage and whether or not the patient will show any improvement in her neurologic status?

           2.  “Prognosis was incompatible with the patient’s wishes. (33.8%)”

 This is a “He wouldn’t want to live this way” kind of reasoning. If the physicians for this patient could say to the family, something like: “I can tell you with authority that your son will never be able to have any modicum of awareness, he will never eat on his own, …” If this could be established then the “He wouldn’t want to live this way” reasoning may be an ethically sufficient decision, if in fact the wishes of the patient are clear. However, without such a established prognosis, how can we arrive at a reasonable assessment as to what, exactly, the patient would want. There is little ability to actually assess whether decisions to withdraw life support are genuinely the patient wishes or the wishes of others.

The question that must be posed is whether or not waiting will clarify the prognosis of the patient. If so, then it is indeed premature to withdraw. The fact that, as determined in this study, most patients die after withdrawal from ventilation support, serves to emphasize the need to wait.

“A poor long-term neurologic prognosis. (28.5%)”

This is a: “he probably will survive, but, …” argument. This is the worse excuse of the three listed. It states that: “he probably will survive and if we do not remove life support while he still needs it, someone will probably have to take care of him later. This is tantamount to homicide. We have a non-terminal patient with undetermined future neurologic status who we are going to withdraw life sustaining care to end his life. The total number of patients studied in this cohort was 720. 492 patients did survive, with considerable variability between the participating medical centers.  The authors’ state:

“This raises the concern that differences in mortality between centers may be partly due to variation in physician’s perceptions of long-term prognosis and physicians practice patterns for recommending withdrawal of life-sustaining therapy.”

It is the job of the physicians to treat the patient, not satisfy the needs of the family. Hence, great care must be taken to determine and effectuate the wishes of the patient.

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