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Decision making in a life-threatening cerebral condition: a comparative study of the ethical reasoning of intensive care unit physicians and neurosurgeons
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
2007 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 51, no 10, 1338-1343 p.Article in journal (Other academic) Published
Abstract [en]

Severe traumatic brain injury (TBI) is one of the major causes of death in younger age groups. In Umea, Sweden, an intracranial pressure (ICP) targeted therapy protocol, the Lund concept, has been used in treatment of severe TBI since 1994. Decompressive craniectomy is used as a protocol-guided treatment step. The primary aim of the investigation was to study the effect of craniectomy on ICP changes over time in patients with severe TBI treated by an ICP-targeted protocol. In this retrospective study, all patients treated for severe TBI during 1998-2001 who fulfilled the following inclusion criteria were studied: GCS <or= 8 at intubation and sedation, first recorded cerebral perfusion pressure (CPP) of >10 mm Hg, arrival within 24 h of trauma, and need of intensive care for >72 h. Craniectomy was performed when the ICP could not be controlled by evacuation of hematomas, sedation, ventriculostomy, or low-dose pentothal infusion. Ninety-three patients met the inclusion criteria. Mean age was 37.6 years. Twenty-one patients underwent craniectomy as a treatment step. We found a significant reduction of the ICP directly after craniectomy, from 36.4 mm Hg (range, 18-80 mm Hg) to 12.6 mm Hg (range, 2-51 mm Hg). During the following 72 h, we observed an increase in ICP during the first 8-12 h after craniectomy, reaching approximately 20 mm Hg, and later levelling out at approximately 25 mm Hg. The reduction of ICP was statistically significant during the 72 h. The outcome as measured by Glasgow Outcome Scale (GOS) did not significantly differ between the craniectomized group (DC) and the non-craniectomized group (NDC). The outcome was favorable (GOS 5-4) in 71% in the craniectomized group, and in 61% in the non-craniectomized group. Craniectomy is a useful tool in achieving a significant reduction of ICP overtime in TBI patients with progressive intracranial hypertension refractory to medical therapy. The procedure seems to have a satisfactory effect on the outcome, as demonstrated by a high rate of favorable outcome and low mortality in the craniectomized group, which did not significantly differ compared with the non-craniectomized group.

Place, publisher, year, edition, pages
2007. Vol. 51, no 10, 1338-1343 p.
Keyword [en]
Brain Injuries/pathology/*surgery, Decision Making, Female, Humans, Intensive Care Units/*ethics, Male, Middle Aged, Neurosurgery/*ethics, Physicians/*ethics
National Category
Medical Ethics Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:umu:diva-10687DOI: 10.1111/j.1399-6576.2007.01452.xISI: 000250249500010PubMedID: 17944637OAI: oai:DiVA.org:umu-10687DiVA: diva2:150358
Available from: 2008-10-17 Created: 2008-10-17 Last updated: 2016-12-20Bibliographically approved
In thesis
1. Withhold  or  withdraw  futile  treatment in  intensive  care: arguments supported by physicians and the general public
Open this publication in new window or tab >>Withhold  or  withdraw  futile  treatment in  intensive  care: arguments supported by physicians and the general public
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Since the 60s and with increasing intensity a discussion have continued about balance between useful and useless/harmful treatment. Different attempts have been done to create sustainable criteria and recommendations to manage the situations of futile treatment near the end of life. Obviously, to be able to withhold (WH) or withdraw (WD) treatment which is no longer appropriate or even harmful and burdensome for the patient, other processes than strict medical (or physiological) assessments are necessary.

Aim. To shed light on the arguments regarding to WH or WD futile treatment we performed two studies of physicians’ and the general populations’ choice and prioritized arguments in the treatment of a 72-year-old woman suffering from a large intra-cerebral bleeding with bad prognosis (Papers I and II) and a new born boy with postpartum anoxic brain damage (Papers III and IV).

Methods. Postal questionnaires based on two cases presented above involving severely ill patients were used. Arguments for and against to WH or WD treatment, and providing treatment that might hasten death were presented. The respondents evaluated and prioritized arguments for and against withholding neurosurgery, withdrawing life-sustaining treatment and providing drugs to alleviate pain and distress. We also asked what would happen to physicians’ own trust if they took the action described, and what the physician estimated would happen to the general publics’ trust in health services (Paper IV).

Results. Approximately 70% of the physicians and 46% of the general public responded in both surveys. The 72-year-old woman: A majority of doctors (82.3%) stated that they would withhold treatment, whereas a minority of the general public (40.2%) would do so; the arguments forwarded and considerations regarding quality of life differed significantly between the two groups. Quality-of-life aspects were stressed as an important argument by the majority of both neurosurgeons and ICU-physicians (76.8% vs. 54.0%); however, significantly more neurosurgeons regarded this argument as the most important. A minority in both groups, although more ICU-physicians, supported a patient’s previously expressed wish of not ending in a persistent vegetative state as the most important argument. As the case clinically progressed, a consensus evolved regarding the arguments for decision making.

The new born child: A majority of both physicians [56 % (CI 50–62)] and the general population [53 % (CI 49–58)] supported arguments for withdrawing ventilator treatment. A large majority in both groups supported arguments for alleviating the patient’s symptoms even if the treatment hastened death, but the two groups display significantly different views on whether or not to provide drugs with the additional intention of hastening death, although the difference disappeared when we compared subgroups of those who were for or against euthanasia-like actions.

Conclusions. There are indeed considerable differences in how physicians and the general public assess and reason in critical care situations, but the more hopelessly ill the patient became the more the groups' assessments tended to converge, although they prioritized different arguments. In order to avoid unnecessary dispute and miscommunication, it is important that health care providers are aware of the public's views, expectations, and preferences. Our hypothesis—physicians’ estimations of others’ opinions are influenced by their own opinions—was corroborated. This might have implications in research as well as in clinical decision-making.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. 95 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1870
Keyword
Withdrawal life-sustaining treatment, Futility, Neonatal intensive care, Intentions, Hastening Death, Value-based medicine, Evidence-based medicine, Decision-making, Personal values
National Category
Medical Ethics Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:umu:diva-128863 (URN)978-91-7601-629-9 (ISBN)
Public defence
2017-01-20, Sal 933, byggnad 3A, 9tr, Norrlands Universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Funder
Vårdal FoundationSwedish Society of Medicine
Available from: 2016-12-21 Created: 2016-12-16 Last updated: 2016-12-21Bibliographically approved

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Rydvall, AndersBergenheim, Tommy

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