Prognostication and shared decision making in neurocritical careBMJ 2022; 377 doi: https://doi.org/10.1136/bmj-2021-060154 (Published 07 April 2022) Cite this as: BMJ 2022;377:e060154
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Dr Goostrey and Professor Muehlschlegel have written a state of the art review of the "science" of forecasting and decision making post severe brain injury. An initial comment could be to ask why are so many people in ITU in the first place? Could a decision upstream to select hopeful cases for admission to ITU not be made? This may sound radical and it is, but it begs the question: Are too many inappropriate people admitted to intensive care with resulting escalating morbidity and life/death decisions having to be made? ITU is expensive and resource rich and should have strict admission criteria. It may give false hope and prolong futility for people to know their relative is in ITU. More stringent admission criteria should be established for ITU admission based on futility/survival hope, cost, resources and its extraordinary ethical nature. What is extraordinary medical care that you ethically do not have to avail of if you wish? ITU may be such an extraordinary intervention for some patients.
On a more fundamental note you could ask what the basic foundation for decision making in ITU is? The review in question discusses terms and conditions of prognosis, decision trees, multidisciplinary cooperation and the science as good as it is today. It is all very pragmatic as it should be - factual and uncertain - but I think respect for life and refusal to harm life (by withdrawal of food and fluids) should be a basic decision foundation. The idea of extraordinary intervention not being ethically required may help. To protect life you have to avail of ordinary means. Withdrawing life sustaining treatments is in essence an ethical decision and the natural law states that you cannot take life or harm life.
This is becoming an enormous issue with advanced medical care and increasing age of the population, and the risk of inadvertently or advertently wandering into medical assisted death, euthanasia, and assisted suicide. The stakes are big - resource allocation to ITUs and resulting rehab needs, and costs and burden on carers and family. This is why the debate or overview needs to couch the entire outlook on ethically acceptable criteria. Those with the best decision trees science can offer may help relatives and doctors in this area.
Competing interests: No competing interests