Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands

Inge A M van Erp; T A van Essen; Erwin J O Kompanje; Mathieu van der Jagt; Wouter A Moojen; Wilco C Peul; Jeroen T J M van Dijck

doi:10.1016/j.bas.2024.102746

Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands

Brain Spine. 2024 Jan 3:4:102746. doi: 10.1016/j.bas.2024.102746. eCollection 2024.

Authors

Inge A M van Erp¹, T A van Essen^{1

2}, Erwin J O Kompanje^{3

4}, Mathieu van der Jagt³, Wouter A Moojen¹, Wilco C Peul¹, Jeroen T J M van Dijck¹

Affiliations

¹ University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands.
² Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom.
³ Department of Intensive Care Adults, Erasmus MC - University Medical Center, Rotterdam, the Netherlands.
⁴ Department of Ethics and Philosophy of Medicine, Erasmus MC - University Medical Center, Rotterdam, the Netherlands.

Abstract

Introduction: Treatment-limiting decisions (TLDs) can be inevitable severe traumatic brain injury (s-TBI) patients, but data on their use remain scarce.

Research question: To investigate the prevalence, timing and considerations of TLDs in s-TBI patients.

Material and methods: s-TBI patients between 2008 and 2017 were analysed retrospecively. Patient data, timing, location, involvement of proxies, and reasons for TLDs were collected. Baseline characteristics and in-hospital outcomes were compared between s-TBI patients with and without TLDs.

Results: TLDs were reported in 117 of 270 s-TBI patients (43.3%) and 95.9% of deaths after s-TBI were preceded by a TLD. The majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ-support in 64.1%. Neurosurgical intervention was withheld in 29.9%. The median time from admission to TLD was 2 days [IQR, 0-8] and 50.4% of TLDs were made within 3 days of admission. The main reason for a TLD was that the patients were perceived as unsalvageable (66.7%). Nearly all decisions were made multidisciplinary (99.1%) with proxies involvement (75.2%). The predicted mortality (CRASH-score) between patients with and without TLDs were 72.6 vs. 70.6%. The percentage of TLDs in s-TBI patients increased from 20.0% in 2008 to 42.9% in 2012 and 64.3% in 2017.

Discussion and conclusion: TLDs occurred in almost half of s-TBI patients and were instituted more frequently over time. Half of TLDs were made within 3 days of admission in spite of baseline prognosis between groups being similar. Future research should address whether prognostic nihilism contributes to self-fulfilling prophecies.

Keywords: Prognosis; Severe traumatic brain injury; Treatment-limiting decision.