Life Support Withdrawn Too Soon in Severe TBI?
Some patients with severe traumatic brain injury (TBI) who died because life support was withdrawn may have survived and recovered at least partial independence if the life sustaining treatment had continued, new research shows.
Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) suggest that delaying decisions on life-support withdrawal might be beneficial for some patients.
“We found that a significant proportion of patients who died after life support was removed may have died anyway, even if their life support had been continued,” study investigator Yelena Bodien, PhD, Department of Neurology, Massachusetts General Hospital, and Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, and Harvard Medical School, Boston, told Medscape Medical News.
“But the remarkable and unexpected finding was that among patients who were estimated to have survived if life support was not withdrawn, as many as 40% were predicted to recover some level of independence by 6 months after injury,” she added.
However, the investigators noted that none of the patients who died in this study were pronounced brain-dead, so the results are not applicable to brain death.
The study was published online on May 13 in the Journal of Neurotrauma.
Predicting Outcomes: A Challenge
Predicting outcomes after severe TBI can be challenging, and there are currently no medical guidelines or precise algorithms that determine which patients are likely to recover, researchers noted. Yet, they added, families are often asked to make decisions about life-support withdrawal within 72 hours of severe TBI.
The study included more than 1300 patients with severe TBI at 18 trauma centers across the United States. Investigators created a mathematical model to estimate the potential for recovery of at least partial function 6 months after injury. They then developed propensity-score matched cohorts of patients with severe TBI with and without withdrawal of life-sustaining treatment in the intensive care unit.
To optimize matching due to uneven distribution of propensity scores, they divided the cohort that remained on life support into tiers on the basis of propensity for withdrawal (Tier 1, 0%-11%; Tier 2, 11%-27%; and Tier 3, 27%-70%).
A total of 56 patients did not have life support withdrawn. At 6 months, 31 (55%) died, but 25 (45%) survived. Survival was 88%, 54%, and 24% for Tier 1, 2, and 3, respectively.
‘Cautionary Approach’ Warranted
Glasgow Outcome Scale-Extended (GOSE) data at 6 months were available for 10 of 15 (67%) patients who remained on life support in Tier 1, 19 of 25 (76%) in Tier 2, and 27 of 40 (68%) in Tier 3.
Recovery of at least partial independence (GOSE ≥ 4) occurred in more than 40% of survivors in the full sample and in Tiers 1 and 2.
In Tiers 1 and 2 combined, four patients recovered to pre-injury baseline levels of function (GOSE of 8). Eight patients in Tiers 1 and 2 recovered to GOSE of 3, indicating a lower severe disability category that includes a broad range of function and may include some patients who are independent in activities of daily living.
The current findings support recent calls for a cautionary approach toward early decisions regarding withdrawal of life support, investigators noted.
However, death or severe disability were common outcomes, especially for patients in Tier 3, with the highest propensity for withdrawal of life support in the matched cohort, Bodien noted, “indicating that providers are often correct in identifying patients for whom survival or independence at 6 months is unlikely.”
“These are patients who typically have life support withdrawn because they are expected to have no chance for recovery and our results suggest that maybe that would not have been the case,” said Bodien. “We hope our findings prompt clinicians to pause before recommending something that is so irreversible and grave as withdrawing life support before they talk to families and present that as an option.”
“A lot more work is needed in this area, especially in trying to improve our accuracy for predicting how patients who have had a severe TBI will recover, but at a minimum, studies like these will hopefully encourage clinicians to be cautious when considering withdrawing life support in patients with severe TBI,” she added.
Outside Experts Weigh In
Reached for comment, Tatyana Mollayeva, MD, PhD, Canada Research Chair in Neurological Disorders and Brain Health and associate director of the Acquired Brain Injury Lab, University of Toronto, said that this study is “important because it highlights new directions for scientific inquiry” concerning several issues.
They include “validity of consent as it relates to acceptance and refusal of life-sustaining treatment; competence of family members/surrogates who have to make decisions on a patient’s behalf in a time of great distress; and confidence in clinical judgment and differential diagnosis, given the neurodiversity of processes,” Mollayeva, who was not involved in the study, told Medscape Medical News.
Ariane Lewis, MD, director of neurocritical care, NYU Langone Medical Center, New York, NY, said, “It has long been recognized that our understanding of recovery after acute brain injury has been jaded by nihilism and the self-fulfilling prophecy — the expectation of a bad outcome leading to premature withdrawal of life-sustaining treatment which results in death.”
“It is important to note that factors associated with the decision to withdrawal life-sustaining treatment — such as previously stated beliefs about quality-of-life, prior dependency, religion, and other medical problems — were not incorporated into this study and the content of goals-of-care discussions is unknown,” said Lewis, who was not involved in the study.
“Nonetheless, it is important to understand that the time course for recovery after acute brain injury can be many months,” she added. “People should discuss these wishes with family and friends to ensure they are followed in the unfortunate event of acute brain injury precluding decision-making capacity.”
Also weighing in, David Greer, MD, professor and chair, Department of Neurology, Boston University School of Medicine, Massachusetts, told Medscape Medical News that this is a “very important” study, performed in a “very responsible and prudent manner.”
Greer said the findings “validate what we’ve been concerned about all along, that being there is a self-fulfilling prophecy bias to have withdrawal of life-sustaining therapy prematurely in patients who may be destined for a good outcome.”
“I think this plants the seeds for future prospective studies that will evaluate this in a manner that allows patients to live for longer, and find more reliable signs that they may recover in a delayed fashion. Certainly very exciting news from this study,” said Greer.
Developing Evidence-Based Prognostic Tools Essential
Also reached for comment was Shaheen Lakhan, MD, PhD, a neurologist and researcher based in Miami, Florida, who told Medscape Medical News that the current state of neuroprognostication “often leaves us in the dark, relying on fragmented data and uncertain outcomes to guide these critical decisions. This uncertainty can lead to premature withdrawal of life-sustaining treatments, potentially denying some patients the opportunity for meaningful recovery.”
The advancement of comprehensive and evidence-based prognostic tools is essential, he added.
“By incorporating a wide range of clinical, demographic, and biometric data, these models can improve the precision of our predictions. Investments in research and technology are crucial to develop these tools, which should be readily available and integrated into standard clinical practice,” Lakhan said.
He urged the medical community, researchers, policymakers, and society at large to participate in this endeavor.
“Let us move forward from the shadows of uncertainty and embrace a future where every decision is informed by the best possible evidence, where every family is supported with compassion and clarity, and where every patient is given the fairest chance at recovery,” he said. “Together, we can advance neuro-prognostication from the dark ages into an era of enlightenment and hope.”
This work is supported by grants from National Institute of Neurological Disorders and Stroke, National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), National Institutes of Health (NIH) Director’s Office, James S. McDonnell Foundation, Chen Institute MGH Research Scholar Award, US Department of Defense (DoD), and US Department of Energy. The authors and Mollayeva, Lewis, Greer, and Lakhan have no relevant disclosures.
