Once again, an item featured on Thaddeus Pope‘s Medical Futility Blog turned out to be something that I wanted to explore in greater detail than the brief blurb given on his blog, in his September 10th post, Hospitals Vary in How Quickly LST Is Stopped:
In “Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study,” forthcoming in CMAJ, Alexis Turgeon and colleagues examined the treatment of traumatic brain injury across Canadian hospitals. They report “considerable variability” in the rate of withdrawal of life-sustaining therapy. At some facilities withdrawal is quite early, often within three days of ICU admission.
Life-sustaining treatment is usually withdrawn because of a poor chance of survival or because of a prognosis incompatible with the patient’s wishes. But the authors conclude that since “there are few accurate and useful prediction tools” prognostication for these patients relies heavily upon “physicians’ perceptions” and “physicians’ practice patterns.” This, they suggest, explains wide variation in the rate and speed at which life-sustaining treatment is withdrawn.
This findings are more detailed and go somewhat farther than this brief summary suggests. Fortunately, the abstract is freely accessible at the CMAJ link above. Even better, the full article is available in pdf.
Early in the article, the authors highlight the lack of reliable reliable predictive tools in terms the “meaningful recovery of individuals with severe traumatic brain injury (but, as the researchers find, that doesn’t prevent predictions from being made very early). They assert a need for understanding more about treatment withdrawal decisions in the context of the ongoing discussions regarding organ donation:
The subjective nature of neuroprognostication
may lead to variability in the incidence
of death associated with the withdrawal of lifesustaining
therapy. With the recent advent of
programs for organ donation following cardiovascular
death, potential variability in mortality
and withdrawal of life-sustaining therapy
among patients with severe traumatic brain
injury would be of major importance from a
medicolegal perspective. The ethical debate
surrounding organ donation following cardiovascular
death having recently reached a public
hearing9 highlights the need to improve our
understanding of withdrawal of life-sustaining
therapy for this specific population of patients.
That’s pretty much all they say, but I find the context and the careful phrasing interesting. Without coming out and saying it, are the authors voicing a concern that we’re not trying hard enough to get real data on tools to predict recovery in people with severe brain trauma before we start making decisions in which organ harvesting is part of the mix? It’s impossible to say – that’s the one and only reference to organ donation in the article.
Without going into the nitty gritty of the data presented in the various tables and in the text, I’ll share the conclusions and leave it to interested readers to dig into the data for more detail than I’ve shared here. I’ll share the Conclusion of the article, which I think gives enough pause for thinking about. It certainly clears up any future speculations that people with severe traumatic brain injury whose life-support is withdrawn within days of their injury are not “miracles” in the sense that they had any chance at recovery. The “miracle” is that they managed to survive the withdrawal of life-sustaining treatment at a time when most other individuals would not – simple because of how early this is done in the recovery process – a time when many people who eventually recover are dependent on life-sustaining treatment.
Here’s the Conclusion:
The high proportion of deaths in all centres following
withdrawal of life-sustaining therapy,
specifically in the early phase of care, is concerning
when placed in the context of limited
ability to accurately determine prognosis for
patients with severe traumatic brain injury. Our
study highlights the need for high-quality re –
search to better inform decisions to stop life –
sustaining treatments for these patients. However,
our study was not intended to compare the
quality of hospitals based on differences in care
practices and mortality after traumatic brain
injury. We therefore have not publicly linked
hospital names to outcome data to avoid the
potential for drawing spurious inferences about
the quality of care.24 (Emphasis added.)Despite our robust analysis, observed differences
in adjusted mortality across centres may
still represent residual confounding by unmeasured
factors.25 Furthermore, some patients may
consider death to be a preferable outcome to living
in a permanent vegetative state or coma. In
such situations, withdrawal of life-sustaining
therapies may be the most acceptable option of
care for families, relatives and medical teams
according to patients’ wishes and the philosophy
of care. However, caution is warranted regarding
prognostication and early withdrawal of life –
sustaining therapy following severe traumatic
brain injury before accurate and clinically useful
prognostic tests and models are available. (Emphasis added.)
As I said before, I welcome other readers to dig into the study and share reactions and insights here. –Stephen Drake
Stephen, I wanted to express my appreciation for sharing this. I am extremely frightened by the way that many of us (PWD) are now having our lives shortened so that our organs can be harvested for those who are considered more valuable to society. It brings up the issue of the hierarchy that exists even within the population of disabled people. If a donated organ would give someone the opportunity to live longer, is it ethical to take it knowing that it was only available because another life was shortened/ended?
Thanks for digging in on this. While this implication was not drawn out in the article, the significant variability in practice MAY BE influenced not just by different medical training but also by differences in provider bias and prejudice.
Bint –
There are a large number of serious ethical questions in terms of transplant practices – both current ones and ones that are being proposed. You can search the blog for some previous entries dealing with transplantation – and there will be more in the future.
To Thaddeus Pope – I think the authors were very careful not to cite any specific factors so as not to offend or upset participating medical professionals more than the fact of great variability would already. It reminded me of the Neurology article citing the lack of adherence to AAN criteria for determining brain death. The authors did everything possible to avoid saying “some of you have killed people who weren’t really dead.”
I think there’s another possible factor at work at the hospitals with the high rates of early withdrawal. I’ll email you an article tomorrow that I just ordered today.