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Muehlschlegel S. Prognostication in Neurocritical Care. Continuum (Minneap Minn) 2024; 30:878-903. [PMID: 38830074 DOI: 10.1212/con.0000000000001433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication. LATEST DEVELOPMENTS Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care. ESSENTIAL POINTS This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.
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Leslie-Mazwi TM. Neurocritical Care for Patients With Ischemic Stroke. Continuum (Minneap Minn) 2024; 30:611-640. [PMID: 38830065 DOI: 10.1212/con.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Management of stroke due to large vessel occlusion (LVO) has undergone unprecedented change in the past decade. Effective treatment with thrombectomy has galvanized the field and led to advancements in all aspects of care. This article provides a comprehensive examination of neurologic intensive care unit (ICU) management of patients with stroke due to LVO. The role of the neurocritical care team in stroke systems of care and the importance of prompt diagnosis, initiation of treatment, and continued monitoring of patients with stroke due to LVO is highlighted. LATEST DEVELOPMENTS The management of complications commonly associated with stroke due to LVO, including malignant cerebral edema and respiratory failure, are addressed, stressing the importance of early identification and aggressive treatment in mitigating negative effects on patients' prognoses. In the realm of medical management, this article discusses various medical therapies, including antithrombotic therapy, blood pressure management, and glucose control, outlining evidence-based strategies for optimizing patient outcomes. It further emphasizes the importance of a multidisciplinary approach to provide a comprehensive care model. Lastly, the critical aspect of family communication and prognostication in the neurologic ICU is addressed. ESSENTIAL POINTS This article emphasizes the multidimensional aspects of neurocritical care in treating patients with stroke due to LVO.
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Aude CA, Vattipally VN, Das O, Ran KR, Giwa GA, Rincon-Torroella J, Xu R, Byrne JP, Muehlschlegel S, Suarez JI, Mukherjee D, Huang J, Azad TD, Bettegowda C. Machine Learning Identifies Variation in Timing of Palliative Care Consultations Among Traumatic Brain Injury Patients. RESEARCH SQUARE 2024:rs.3.rs-4290808. [PMID: 38746163 PMCID: PMC11092864 DOI: 10.21203/rs.3.rs-4290808/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Background and Objective Timely palliative care involvement offers demonstrable benefits for traumatic brain injury (TBI) patients; however, palliative care consultations (PCCs) are used inconsistently during TBI management. This study aimed to employ advanced machine learning techniques to elucidate the primary drivers of PCC timing variability for TBI patients. Methods Data on admission, hospital course, and outcomes were collected for a cohort of 232 TBI patients who received both PCCs and neurosurgical consultations during the same hospitalization. Principal Component Analysis (PCA) and K-means clustering were used to identify patient phenotypes, which were then compared using Kaplan-Meier analysis. An extreme gradient boosting model (XGBoost) was employed to determine drivers of PCC timing, with model interpretation performed using SHapley Additive exPlanations (SHAP). Results Cluster A (n = 86) consisted mainly of older (median [IQR] = 87 [78, 94] years), White females with mild TBIs and demonstrated the shortest time-to-PCC (2.5 [1.0, 7.0] days). Cluster B (n = 108) also sustained mild TBIs but comprised moderately younger (81 [75, 86] years) married White males with later PCC (5.0 [3.0, 10.8] days). Cluster C (n = 38) represented much younger (46.5 [29.5, 59.8] years), more severely injured, non-White patients with the latest PCC initiation (9.0 [4.2, 17.0] days). The clusters did not differ by discharge disposition (p = 0.4) or frequency inpatient mortality (p > 0.9); however, Kaplan-Meier analysis revealed a significant difference in the time from admission to PCC (p < 0.001), despite no differences in time from admission to mortality (p = 0.18). SHAP analysis of the XGBoost model identified age, sex, and race as the most influential drivers of PCC timing. Conclusions This study highlights crucial disparities in PCC timing for TBI patients and underscores the need for targeted strategies to ensure timely and equitable palliative care integration for this vulnerable population.
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Affiliation(s)
| | | | - Oishika Das
- The Johns Hopkins University School of Medicine
| | | | | | | | - Risheng Xu
- The Johns Hopkins University School of Medicine
| | | | | | | | | | - Judy Huang
- The Johns Hopkins University School of Medicine
| | - Tej D Azad
- The Johns Hopkins University School of Medicine
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Maiga AW, Cook M, Nordness MF, Gao Y, Rakhit S, Rivera EL, Harrell FE, Sharp KW, Patel MB. Surrogate Perception of Disability after Hospitalization for Traumatic Brain Injury. J Am Coll Surg 2024; 238:589-597. [PMID: 38214447 PMCID: PMC10947846 DOI: 10.1097/xcs.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
BACKGROUND The Glasgow Outcome Scale Extended (GOSE) is a measure of recovery after traumatic brain injury (TBI). Public surveys rate some GOSE states as worse than death. Direct family experience caring for patients with TBI may impact views of post-TBI disability. STUDY DESIGN We conducted a national cross-sectional computer-adaptive survey of surrogates of TBI dependents incurring injury more than 1 year earlier. Using a standard gamble approach in randomized order, surrogates evaluated preferences for post-TBI GOSE states from GOSE 2 (bedridden, unaware) to GOSE 8 (good recovery). We calculated median (interquartile range [IQR]) health utilities for each post-TBI state, ranging from -1 to 1, with 0 as reference (death = GOSE 1), and assessed sociodemographic associations using proportional odds logistic regression modeling. RESULTS Of 515 eligible surrogates, 298 (58%) completed scenarios. Surrogates were median aged 46 (IQR 35 to 60), 54% married, with Santa Clara strength of faith 14 (10 to 18). TBI dependents had a median GOSE5 (3 to 7). Median (IQR) health utility ratings for GOSE 2, GOSE 3, and GOSE 4 were -0.06 (-0.50 to -0.01), -0.01 (-0.30 to 0.45), and 0.30 (-0.01 to 0.80), rated worse than death by 91%, 65%, and 40%, respectively. Surrogates rated GOSE 4 (daily partial help) worse than the general population. Married surrogates rated GOSE 4 higher (p < 0.01). Higher strength of faith was associated with higher utility scores across GOSE states (p = 0.034). CONCLUSIONS In this index study of surrogate perceptions about disability after TBI, poor neurologic outcomes-vegetative, needing all-day or partial daily assistance-were perceived as worse than death by at least 1 in 3 surrogates. Surrogate perceptions differed from the unexposed public. Long-term perceptions about post-TBI disability may inform earlier, tailored shared decision-making after neurotrauma.
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Affiliation(s)
- Amelia W. Maiga
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
| | - Madison Cook
- Department of Surgery, Temple University Hospital, 3401 N. Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA 19140
| | - Mina F. Nordness
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
| | - Yue Gao
- Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN 37203
| | - Shayan Rakhit
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
| | - Erika L. Rivera
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
| | - Frank E. Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN 37203
| | - Kenneth W. Sharp
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
| | - Mayur B. Patel
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN 37212
- Critical Illness, Brain dysfunction, and Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN 37203
- Vanderbilt University Medical Center; Geriatric Research Education and Clinical Center; Surgical Services, Tennessee Valley Healthcare System
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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Mead G. Shared decision making in older people after severe stroke. Age Ageing 2024; 53:afae017. [PMID: 38364821 DOI: 10.1093/ageing/afae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Indexed: 02/18/2024] Open
Abstract
Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.
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Affiliation(s)
- Gillian Mead
- Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh EH16 4SA, UK
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Morgenstern LB, Becker CJ, Lank R, Ortiz C, Zhang G, He K, Case E, Zahuranec DB. Long-Term Psychological Distress Among Surrogate Decision Makers for Mexican American and Non-Hispanic White Patients With Severe Stroke. Neurology 2024; 102:e207960. [PMID: 38165320 PMCID: PMC10870740 DOI: 10.1212/wnl.0000000000207960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/06/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES During acute hospitalizations, physicians often focus on the stroke patient and not family who may be traumatized by this sudden change to their loved one. We investigated long-term psychological distress among family surrogate decision makers for Mexican American (MA) and non-Hispanic White (NHW) severe stroke patients. Previous work in other diseases suggested worse psychological outcomes in MA than NHW caregivers. METHODS This was a population-based, prospective cohort study in Nueces County, TX. Stroke patient participants and their surrogate decision makers were enrolled soon after any stroke between April, 2016, and October, 2020, if surrogates had made decisions about life-sustaining treatments. Surrogates completed validated measures of posttraumatic stress, National Stressful Events Survey for Posttraumatic Stress Disorder Short Scale; anxiety, Generalized Anxiety Disorder-7; and depression, Patient Health Questionnaire-8 at discharge, 3, 6, and 12 months. Ethnic differences were assessed with multilevel linear mixed models, sequentially adjusted for prespecified patient and surrogate demographic, socioeconomic, and clinical covariates. RESULTS There were 301 family surrogates for 241 severe stroke patients. The mean follow-up was 315 days. High scores on measures of psychological distress ranged between 17% and 28% of surrogates. One or more high levels of the psychological outcomes were found in 17%-43% of surrogates; 2 or more were found in 12%-27%; and all 3 were found in 5%-16% of surrogates. All psychological outcomes were worse among MAs on unadjusted analyses. In fully adjusted models, posttraumatic stress remained worse among MAs (0.36, 95% CI 0.17-0.56); ethnic differences were attenuated and no longer significant in the final model for anxiety (0.59, 95% CI -0.55 to 1.74) and depression (0.97, 95% CI -0.25 to 2.19). The trajectory for depression did differ by ethnicity (interaction p = 0.03), with depression score improving more rapidly over time among NHWs than MAs. Advance care plans did not seem to confound any ethnic differences. DISCUSSION Psychological distress is common among family surrogate decision makers in the year after stroke and may be worse among MAs. Efforts are needed to support family members of all ethnic groups after severe stroke.
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Affiliation(s)
- Lewis B Morgenstern
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Christopher J Becker
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Rebecca Lank
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Carmen Ortiz
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Guanghao Zhang
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Kevin He
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Erin Case
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
| | - Darin B Zahuranec
- From the Department of Neurology (L.B.M., C.J.B., C.O., D.B.Z.), Michigan Medicine; Center for Social Epidemiology and Population Health (L.B.M.), University of Michigan School of Public Health, Ann Arbor; University of Iowa (R.L.), Iowa City; and Departments of Biostatistics (G.Z., K.H.), and Epidemiology (E.C.), University of Michigan School of Public Health, Ann Arbor
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Jaffa MN, Kirsch HL, Creutzfeldt CJ, Guanci M, Hwang DY, LeTavec D, Mahanes D, Natarajan G, Steinberg A, Zahuranec DB, Muehlschlegel S. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-Care and Family/Surrogate Decision-Maker Data. Neurocrit Care 2023; 39:600-610. [PMID: 37704937 DOI: 10.1007/s12028-023-01796-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND To facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDEs) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC. METHODS To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the National Institutes of Health/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core", "basic", "exploratory", or "supplemental", as well as their use for studying the acute or chronic phase of DoC, or both. RESULTS We identified 32 relevant preexisting National Institutes of Health CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup. CONCLUSIONS Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.
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Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Hannah L Kirsch
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Road, MC 5235, Palo Alto, CA, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, Division of Stroke and Palliative Care, University of Washington, Seattle, WA, USA
| | - Mary Guanci
- Department of Neuroscience Nursing, Massachusetts General Hospital, Boston, MA, USA
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit Medical Center, Detroit, MI, USA
| | - Alexis Steinberg
- Department of Neurology, Critical Care Medicine, and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Darin B Zahuranec
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Fleming V, Prasad A, Ge C, Crawford S, Meraj S, Hough CL, Lo B, Carson SS, Steingrub J, White DB, Muehlschlegel S. Prevalence and predictors of shared decision-making in goals-of-care clinician-family meetings for critically ill neurologic patients: a multi-center mixed-methods study. Crit Care 2023; 27:403. [PMID: 37865797 PMCID: PMC10590503 DOI: 10.1186/s13054-023-04693-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Shared decision-making is a joint process where patients, or their surrogates, and clinicians make health choices based on evidence and preferences. We aimed to determine the extent and predictors of shared decision-making for goals-of-care discussions for critically ill neurological patients, which is crucial for patient-goal-concordant care but currently unknown. METHODS We analyzed 72 audio-recorded routine clinician-family meetings during which goals-of-care were discussed from seven US hospitals. These occurred for 67 patients with 72 surrogates and 29 clinicians; one hospital provided 49/72 (68%) of the recordings. Using a previously validated 10-element shared decision-making instrument, we quantified the extent of shared decision-making in each meeting. We measured clinicians' and surrogates' characteristics and prognostic estimates for the patient's hospital survival and 6-month independent function using post-meeting questionnaires. We calculated clinician-family prognostic discordance, defined as ≥ 20% absolute difference between the clinician's and surrogate's estimates. We applied mixed-effects regression to identify independent associations with greater shared decision-making. RESULTS The median shared decision-making score was 7 (IQR 5-8). Only 6% of meetings contained all 10 shared decision-making elements. The most common elements were "discussing uncertainty"(89%) and "assessing family understanding"(86%); least frequent elements were "assessing the need for input from others"(36%) and "eliciting the context of the decision"(33%). Clinician-family prognostic discordance was present in 60% for hospital survival and 45% for 6-month independent function. Univariate analyses indicated associations between greater shared decision-making and younger clinician age, fewer years in practice, specialty (medical-surgical critical care > internal medicine > neurocritical care > other > trauma surgery), and higher clinician-family prognostic discordance for hospital survival. After adjustment, only higher clinician-family prognostic discordance for hospital survival remained independently associated with greater shared decision-making (p = 0.029). CONCLUSION Fewer than 1 in 10 goals-of-care clinician-family meetings for critically ill neurological patients contained all shared decision-making elements. Our findings highlight gaps in shared decision-making. Interventions promoting shared decision-making for high-stakes decisions in these patients may increase patient-value congruent care; future studies should also examine whether they will affect decision quality and surrogates' health outcomes.
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Affiliation(s)
- Victoria Fleming
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Abhinav Prasad
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Departments of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Connie Ge
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Sybil Crawford
- Tan Chingfen University of Massachusetts Graduate School of Nursing, Worcester, MA, USA
| | - Shazeb Meraj
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Catherine L Hough
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shannon S Carson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Jay Steingrub
- Division of Pulmonary Medicine and Critical Care Medicine, Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Departments of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Departments of Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA.
- Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Phipps 455, Baltimore, MD, 21287, USA.
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10
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Lissak IA, Edlow BL, Rosenthal E, Young MJ. Ethical Considerations in Neuroprognostication Following Acute Brain Injury. Semin Neurol 2023; 43:758-767. [PMID: 37802121 DOI: 10.1055/s-0043-1775597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Neuroprognostication following acute brain injury (ABI) is a complex process that involves integrating vast amounts of information to predict a patient's likely trajectory of neurologic recovery. In this setting, critically evaluating salient ethical questions is imperative, and the implications often inform high-stakes conversations about the continuation, limitation, or withdrawal of life-sustaining therapy. While neuroprognostication is central to these clinical "life-or-death" decisions, the ethical underpinnings of neuroprognostication itself have been underexplored for patients with ABI. In this article, we discuss the ethical challenges of individualized neuroprognostication including parsing and communicating its inherent uncertainty to surrogate decision-makers. We also explore the population-based ethical considerations that arise in the context of heterogenous prognostication practices. Finally, we examine the emergence of artificial intelligence-aided neuroprognostication, proposing an ethical framework relevant to both modern and longstanding prognostic tools.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Eric Rosenthal
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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11
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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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12
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Lei Y, Zhou Q, Tao Y. Decision Aids in the ICU: a scoping review. BMJ Open 2023; 13:e075239. [PMID: 37607783 PMCID: PMC10445349 DOI: 10.1136/bmjopen-2023-075239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
OBJECTIVE The purpose of this scoping review was to synthesise the effectiveness and acceptability of decision aids for critically ill patients and family members in the intensive care unit (ICU). METHODS A systematic search of four electronic databases and grey literature was undertaken to identify relevant studies on the application of decision aids in the ICU, without publication date restriction, through March 2023. The methodological framework proposed by Arksey and O'Malley was used to guide the scoping review. RESULTS Fourteen papers were ultimately included in this review. However, only nine decision aids were available, and it is noteworthy that many of these studies focused on the iterative development and testing of individual decision aids. Among the included studies, 92% (n=13) were developed in North America, with a primary focus on goals of care and life-sustaining treatments. The summary of the effect of decision aid application revealed that the most common indicators were the level of knowledge and code status, and some promising signals disappeared in randomised trials. CONCLUSIONS The complexity of treatment decisions in the ICU exceeds the current capabilities of existing decision aids. There is a clear gap in decision aids that are tailored to different cultural contexts, highlighting the need to expand the scope of their application. In addition, rigorous quality control is very important for randomised controlled trial, and indicators for assessing the effectiveness of decision aids need to be further clarified.
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Affiliation(s)
- Yuling Lei
- Department of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Qi Zhou
- Department of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yuexian Tao
- Department of Nursing, Hangzhou Normal University, Hangzhou, Zhejiang, China
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13
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Rubin MA, Riecke J, Heitman E. Futility and Shared Decision-Making. Neurol Clin 2023; 41:455-467. [PMID: 37407099 DOI: 10.1016/j.ncl.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.
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Affiliation(s)
- Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA.
| | - Jenny Riecke
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Palliative Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA
| | - Elizabeth Heitman
- Program in Ethics in Science and Medicine, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA; Department of Applied Clinical Research, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA
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14
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Jaffa MN, Hwang DY. Goals of Care for Severe Acute Brain Injury Patients: When a Choice Is Not a Choice. Crit Care Med 2023; 51:978-980. [PMID: 37318295 DOI: 10.1097/ccm.0000000000005879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Matthew N Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT
| | - David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC
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15
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Goss AL, Voumard RR, Engelberg RA, Curtis JR, Creutzfeldt CJ. Do They Have a Choice? Surrogate Decision-Making After Severe Acute Brain Injury. Crit Care Med 2023; 51:924-935. [PMID: 36975213 PMCID: PMC10271970 DOI: 10.1097/ccm.0000000000005850] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES In the early phase of severe acute brain injury (SABI), surrogate decision-makers must make treatment decisions in the face of prognostic uncertainty. Evidence-based strategies to communicate uncertainty and support decision-making are lacking. Our objective was to better understand surrogate experiences and needs during the period of active decision-making in SABI, to inform interventions to support SABI patients and families and improve clinician-surrogate communication. DESIGN We interviewed surrogate decision-makers during patients' acute hospitalization for SABI, as part of a larger ( n = 222) prospective longitudinal cohort study of patients with SABI and their family members. Constructivist grounded theory informed data collection and analysis. SETTING One U.S. academic medical center. PATIENTS We iteratively collected and analyzed semistructured interviews with 22 surrogates for 19 patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Through several rounds of coding, interview notes, reflexive memos, and group discussion, we developed a thematic model describing the relationship between surrogate perspectives on decision-making and surrogate experiences of prognostic uncertainty. Patients ranged from 20 to 79 years of age (mean = 55 years) and had primary diagnoses of stroke ( n = 13; 68%), traumatic brain injury ( n = 5; 26%), and anoxic brain injury after cardiac arrest ( n = 1; 5%). Patients were predominantly male ( n = 12; 63%), whereas surrogates were predominantly female ( n = 13; 68%). Two distinct perspectives on decision-making emerged: one group of surrogates felt a clear sense of agency around decision-making, whereas the other group reported a more passive role in decision-making, such that they did not even perceive there being a decision to make. Surrogates in both groups identified prognostic uncertainty as the central challenge in SABI, but they managed it differently. Only surrogates who felt they were actively deciding described time-limited trials as helpful. CONCLUSIONS In this qualitative study, not all surrogate "decision-makers" viewed themselves as making decisions. Nearly all struggled with prognostic uncertainty. Our findings underline the need for longitudinal prognostic communication strategies in SABI targeted at surrogates' current perspectives on decision-making.
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Affiliation(s)
- Adeline L Goss
- Division of Neurology, Department of Internal Medicine, Highland Hospital, Oakland, CA
| | - Rachel Rutz Voumard
- Department of Medicine, Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Clinical Ethics Unit, Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, WA
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
| | - Claire J Creutzfeldt
- Cambia Palliative Care Center of Excellence at University of Washington, Harborview Medical Center, Seattle, WA
- Department of Neurology, University of Washington, Harborview Medical Center, Seattle, WA
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16
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Jaffa MN, Kirsch HL, Creutzfeldt CJ, Guanci M, Hwang DY, LeTavec D, Mahanes D, Steinberg A, Natarajan G, Zahuranec DB, Muehlschlegel S. Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Goals-of-care and Family/Surrogate Decision-Maker Data. RESEARCH SQUARE 2023:rs.3.rs-3084539. [PMID: 37461521 PMCID: PMC10350109 DOI: 10.21203/rs.3.rs-3084539/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
INTRODUCTION In order to facilitate comparative research, it is essential for the fields of neurocritical care and rehabilitation to establish common data elements (CDE) for disorders of consciousness (DoC). Our objective was to identify CDEs related to goals-of-care decisions and family/surrogate decision-making for patients with DoC. METHODS To achieve this, we formed nine CDE working groups as part of the Neurocritical Care Society's Curing Coma Campaign. Our working group focused on goals-of-care decisions and family/surrogate decision-makers created five subgroups: (1) clinical variables of surrogates, (2) psychological distress of surrogates, (3) decision-making quality, (4) quality of communication, and (5) quality of end-of-life care. Each subgroup searched for existing relevant CDEs in the NIH/CDE catalog and conducted an extensive literature search for additional relevant study instruments to be recommended. We classified each CDE according to the standard definitions of "core," "basic," "exploratory," or "supplemental," as well as their utility for studying the acute or chronic phase of DoC, or both. RESULTS We identified 32 relevant pre-existing NIH CDEs across all subgroups. A total of 34 new instruments were added across all subgroups. Only one CDE was recommended as disease core, the "mode of death" of the patient from the clinical variables subgroup. CONCLUSIONS Our findings provide valuable CDEs specific to goals-of-care decisions and family/surrogate decision-making for patients with DoC that can be used to standardize studies to generate high-quality and reproducible research in this area.
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Affiliation(s)
| | | | | | | | - David Y Hwang
- The University of North Carolina at Chapel Hill School of Medicine
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17
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Egawa S, Ader J, Shen Q, Nakagawa S, Fujimoto Y, Fujii S, Masuda K, Shirota A, Ota M, Yoshino Y, Amai H, Miyao S, Nakamoto H, Kuroda Y, Doyle K, Grobois L, Vrosgou A, Carmona JC, Velazquez A, Ghoshal S, Roh D, Agarwal S, Park S, Claassen J. Long-Term Outcomes of Patients with Stroke Predicted by Clinicians to have no Chance of Meaningful Recovery: A Japanese Cohort Study. Neurocrit Care 2023; 38:733-740. [PMID: 36450972 PMCID: PMC10227183 DOI: 10.1007/s12028-022-01644-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/08/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Little is known about the natural history of comatose patients with brain injury, as in many countries most of these patients die in the context of withdrawal of life-sustaining therapies (WLSTs). The accuracy of predicting recovery that is used to guide goals-of-care decisions is uncertain. We examined long-term outcomes of patients with ischemic or hemorrhagic stroke predicted by experienced clinicians to have no chance of meaningful recovery in Japan, where WLST in patients with isolated neurological disease is uncommon. METHODS We retrospectively reviewed the medical records of all patients admitted with acute ischemic stroke, intracerebral hemorrhage, or nontraumatic subarachnoid hemorrhage between January 2018 and December 2020 to a neurocritical care unit at Toda Medical Group Asaka Medical Center in Saitama, Japan. We screened for patients who were predicted by the attending physician on postinjury day 1-4 to have no chance of meaningful recovery. Primary outcome measures were disposition at hospital discharge and the ability to follow commands and functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), which was assessed 6 months after injury. RESULTS From 860 screened patients, we identified 40 patients (14 with acute ischemic stroke, 19 with intracerebral hemorrhage, and 7 with subarachnoid hemorrhage) who were predicted to have no chance of meaningful recovery. Median age was 77 years (interquartile range 64-85), 53% (n = 21) were women, and 80% (n = 32) had no functional deficits prior to hospitalization. Six months after injury, 17 patients were dead, 14 lived in a long-term care hospital, 3 lived at home, 2 lived in a rehabilitation center, and 2 lived in a nursing home. Three patients reliably followed commands, two were in a vegetative state (GOS-E 2), four fully depended on others and required constant assistance (GOS-E 3), one could be left alone independently for 8 h per day but remained dependent (GOS-E 4), and one was independent and able to return to work-like activities (GOS-E 5). CONCLUSIONS In the absence of WLST, almost half of the patients predicted shortly after the injury to have no chance of meaningful recovery were dead 6 months after the injury. A small minority of patients had good functional recovery, highlighting the need for more accurate neurological prognostication.
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Affiliation(s)
- Satoshi Egawa
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Jeremy Ader
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Qi Shen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Shun Nakagawa
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yoshihisa Fujimoto
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Shuichi Fujii
- Department of Neurointensive Care, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Kenta Masuda
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Akira Shirota
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Masafumi Ota
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yuji Yoshino
- Department of Rehabilitation, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Hitomi Amai
- Department of Social Work, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Satoru Miyao
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Hidetoshi Nakamoto
- Department of Neurosurgery, Stroke and Epilepsy Center, Toda Medical Group Asaka Medical Center, Saitama, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Kagawa, Japan
| | - Kevin Doyle
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Lauren Grobois
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Athina Vrosgou
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Jerina C Carmona
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Angela Velazquez
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Shivani Ghoshal
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - David Roh
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA
- Department of Biomedical Informatics, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York, NY, 10032, USA.
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18
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Wang G, Antel R, Goldfarb M. The Impact of Randomized Family-Centered Interventions on Family-Centered Outcomes in the Adult Intensive Care Unit: A Systematic Review. J Intensive Care Med 2023:8850666231173868. [PMID: 37161268 DOI: 10.1177/08850666231173868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Objective: To review the literature for randomized family-centered interventions with family-centered outcomes in the adult intensive care unit (ICU). Data Sources: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library database from inception until February 2023. Study Selection: We included articles involving randomized controlled trials (RCTs) in the adult critical care setting evaluating family-centered interventions and reporting family-centered outcomes. Data Extraction: We extracted data on author, year of publication, setting, number of participants, intervention category, intervention, and family-centered outcomes. Data Synthesis: There were 52 RCTs included in the analysis, mostly involving communication and receiving information (38%) and receiving care and meeting family member needs (38%). Nearly two-thirds of studies (N = 35; 67.3%) found improvements in at least 1 family-centered outcome. Most studies (N = 24/40; 60%) exploring the impact of family-centered interventions on mental health outcomes showed improvement. Improvements in patient-centered outcomes (N = 7/17; 41%) and healthcare worker outcomes (N = 1/5; 20%) were less commonly found. Conclusions: Family-centered interventions improve family-centered outcomes in the adult ICU and may be beneficial to patients and healthcare workers.
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Affiliation(s)
- Gary Wang
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Ryan Antel
- McGill Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
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Claassen J. Beyond crystal balls: multimodal prediction of early recovery of consciousness. Brain 2023; 146:6-7. [PMID: 36508392 DOI: 10.1093/brain/awac434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
This scientific commentary refers to ‘Multimodal prediction of residual consciousness in the intensive care unit: the CONNECT-ME study’ by Amiri et al. (https://doi.org/10.1093/brain/awac335).
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Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
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20
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Yechoor N, Rosand J. Helping Families With Fateful Decisions. Neurology 2022; 99:593-594. [PMID: 35853749 DOI: 10.1212/wnl.0000000000201145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/06/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nirupama Yechoor
- From the Henry and Allison McCance Center for Brain Health (N.Y., J.R.), Massachusetts General Hospital, Boston; Division of Neurocritical Care (N.Y., J.R.), Massachusetts General Hospital, Boston; Department of Neurology (N.Y., J.R.), Harvard Medical School, Boston; and Program in Medical and Population Genetics (J.R.), the Broad Institute, Cambridge, MA
| | - Jonathan Rosand
- From the Henry and Allison McCance Center for Brain Health (N.Y., J.R.), Massachusetts General Hospital, Boston; Division of Neurocritical Care (N.Y., J.R.), Massachusetts General Hospital, Boston; Department of Neurology (N.Y., J.R.), Harvard Medical School, Boston; and Program in Medical and Population Genetics (J.R.), the Broad Institute, Cambridge, MA.
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