26 May 2024 , 07:00
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The decision to withdraw life support can be a heartbreaking one after a loved one undergoes a traumatic brain injury - it's a delicate balance between maintaining hopes for recovery and also not wanting to prolong suffering.
In these instances, the input from clinicians is often vital and can have a huge impact on the ultimate decision. Most decisions on whether to end life support are made within 72 hours of hospitalisation with the support of critical care doctors. But according to a new paper from the Journal of Neurotrauma, those decisions may be being made too soon.
The study suggests that waiting a little longer and using that time to gather more data could be beneficial. Corresponding author Yelena Bodien, assistant professor of neurology at Massachusetts General Hospital and of physical medicine and rehabilitation at Spaulding Rehabilitation Hospital, said: "There is a lot of uncertainty in the clinical world about which patients are going to recover, to what degree they're going to recover, and when they're going to recover."
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The researchers found evidence to suggest even with the most devastating injuries people may make a recovery (Getty Images/iStockphoto)
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Professor Bodien and her colleagues wanted to find out more about these potential pathways to recovery, and so the enrolled almost 3,100 patients with traumatic brain injuries (TBI) across 18 trauma centres in the US between 2014 and 2021 to learn more. Patients were enrolled in the research within 24 hours of their injuries, with researchers then following about half of them for a year.
Among those they followed, 90 died when life support was removed. The researchers matched them using clinical, demographic and socioeconomic factors to 90 similar patients in the study group whose life support had not been turned off, to compare outcomes.
Patients kept on life support, particularly those who were older and with more severe injuries died in many cases. However, almost 30 per cent of the matched patients made a recovery that saw them returning to at least partial independence within six months.
For some, that meant living with disabilities that still allowed them to take part in life roles they previously held. Others, with less severe injuries, were able to return to normal life. For younger patients with fewer health conditions and less severe injuries, at least 50 per cent regained some form of independence.
"Even though an injury can look quite devastating hours or a few days after it happens, in many cases, we have some evidence to suggest that even with the most devastating injuries people may make a recovery that is meaningful to them months or years later," said Professor Bodien. Though she added that patients whose life support was withdrawn weren't necessarily likely to survive - close to 60 per cent of them would likely have died anyway.
The authors don't suggest life support should always be continued (AFP via Getty Images)She also cautioned that the authors are not suggesting that life support should always be continued. Theresa Williamson, co-author of the study and an assistant professor of neurosurgery at Massachusetts General Hospital and teaching faculty at the Harvard Center for Bioethics cautioned: "What we don't want is to see families prolong suffering, because they're worried that they're missing something.
"I can imagine if I was a family member reading this, I might think, 'Oh my goodness, did I do something wrong? Did I miss it?' And I think the answer is, probably not."
Professor Bodien said the results call for more cooperation between critical care doctors and professionals in rehabilitation settings. The professor, who works in both acute care and rehab, said: "Critical care physicians, they do not have the opportunity to follow their patients long term. THey see a very sick patient with a devastating injury, and they can't even imagine what it might look like over the long term."
On the other side of things, Professor Bodien does acknowledge that rehab doctors may not be as knowledgeable when it comes to understanding the severity of an injury as those in acute care. She said: "[We] need to work together across disciplines to really understand the long term trajectory of recovery."
Ultimately, the study's findings highlight the uncertainty that comes with prognosis after a severe TBI. Professor Williamson said: "Rather than make decisions really early, maybe we should continue the conversation a little longer and look at the trends so that we can better understand how people are doing, rather than being sort of nihilistic about it."
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James Sulzer, a professor in the department of physical medicine and rehabilitation at Case Western Reserve University was not part of the study. But he agreed that waiting some time after a TBI may be a good idea. He said: "We can't predict based on the first few days after an injury what's going to happen very well. We don't know enough about how damage to the brain affects function. We don't know enough about how damage to the brain affects recovery."
Not only could waiting give clinicians more time to make informed decisions, it could also give loved ones the ability to have time to think more clearly about the choice in front of them, according to professor Sulzer. His own daughter experienced a severe brain injury and he recalled how he wasn't in a psychological position for many days to make a decision,
"The overall message," said Professor Bodien, is "a very cautious approach to withdrawal of life sustaining treatment, and perhaps giving people a few extra days to be able to demonstrate their potential for recovery."