Self-Fulfilling Prophecies Through Withdrawal of Care: Do They Exist in Traumatic Brain Injury, Too?
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ORIGINAL ARTICLE
Self-Fulfilling Prophecies Through Withdrawal of Care: Do They Exist in Traumatic Brain Injury, Too? Saef Izzy • Rebecca Compton • Raphael Carandang Wiley Hall • Susanne Muehlschlegel
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Ó Springer Science+Business Media New York 2013
Abstract Objective We examined factors associated with withdrawal of care (WOC) in moderate-severe traumatic brain injury (msTBI) patients, and how WOC may affect shortterm mortality and receipt of neurosurgery. Variability in msTBI-related outcome prognostication by clinicians from different specialties was also assessed. Methods Rates of WOC, factors associated with WOC, and the relation between WOC and in-hospital case-fatality rate (CFR) and neurosurgery were determined in 232 prospectively enrolled msTBI patients in the ongoing OPTIMISM Study at a level-1 trauma center. In a concomitant web-based survey with clinical vignettes, outcome prognostication comfort, treatment aggressiveness, and WOC recommendations were examined among 106 respondents from neurology, neurocritical care, neurosurgery, trauma and anesthesia/critical care. Results The average age of the study sample was 53 years, with a median Glasgow Coma Scale of 6. The in-hospital CFR was 36 and 68 % of patients had WOC. Factors independently associated with WOC were advanced age, pupillary reactivity, lower intensive care unit-length-of-stay, pre- and in-hospital cardiac arrest, herniation, intracranial S. Izzy R. Compton R. Carandang W. Hall Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, Worcester, MA, USA R. Carandang W. Hall Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA S. Muehlschlegel (&) Departments of Neurology (Neurocritical Care), Anesthesia/ Critical Care and Surgery, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655, USA e-mail: [email protected]
pressure crisis, and pre-existing endocrine disease. Inclusion of WOC in our multivariable regression model predicting inhospital CFRs negated all other variables. Survey results suggested that in younger patients, some clinicians prognosticated overly pessimistically based upon data available at the time of presentation. Conclusion In our msTBI cohort, WOC was the most important predictor of in-hospital mortality. We identified several important independent predictors of WOC. Large within-center variability in msTBI outcome prognostication with varying levels of possible clinical nihilism exists, which may form the basis of self-fulfilling prophecies. Keywords Traumatic brain injury Withdrawal of care Prognostication Self-fulfilling prophecies
Introduction Traumatic brain injury (TBI) continues to be a leading cause of death and disability after trauma [1]. The majority of the 275,000 TBI-related hospitalizations and 52,000 deaths annually in the US are comprised of patients with moderate-severe TBI (msTBI) [1]. These patients are commonly admitted to neurological intensive care units (neuroICU
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