Letters Prediction in severe acute brain injury

Early discussions with family of people with severe brain injury

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4568 (Published 28 August 2015) Cite this as: BMJ 2015;351:h4568
  1. Jonathan Ball, consultant in intensive care1
  1. 1St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK
  1. jball{at}sgul.ac.uk

Creutzfeldt and colleagues’ balanced discussion on communicating health trajectories after severe acute brain injury omitted an essential component of early communication and decision making processes—that a short window of opportunity (days) often exists, during which withdrawal of active supportive care, usually mechanical ventilation or vasoactive agents, results in a rapid death.1 Such an approach may be viewed by all concerned as humane and in accordance with the patient’s beliefs.

Living with severe neurodisability, with grossly diminished consciousness, awareness, and autonomy, may be considered a fate worse than death by patients (pre-injury) and their friends and family. The decision to opt for heroic procedures or an extended period of maximal intervention can result in a protracted death based solely on the unlikely event of a recovery. The negative consequences of such a death for patients and their friends and family can be considerable.

As clinicians, our ability to provide an accurate prognosis of the extent of long term neurodisability after severe acute brain injury is limited, especially in the first few days. However, we should not avoid early and open discussions about the consequences of postponing decisions merely to reduce our uncertainty.


Cite this as: BMJ 2015;351:h4568


  • Competing interests: None declared.


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