Access to reliable information about long-term prognosis influences clinical opinion on use of lifesaving intervention

Abstract

Background: Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI.

Method: A two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios.

Results: Five hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] -1.5, 95% confidence interval -1.3 to -1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants.

Conclusions: Access to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.

Figure 1. A fifty two year old female motorcyclist was involved in a motor vehicle accident.

Initial Glasgow coma score was recorded as eleven (Eye: 3, Motor: 6, Verbal response: 2). Pupils were equal and reactive. She had sustained major pelvic and lower limb fractures. CT scan of the brain revealed diffuse petechial haemorrhages, traumatic subarachnoid haemorrhage, non evacuated haematoma and midline shift.

Figure 2. A fifty nine year old male had suffered a fall.

Initial Glasgow coma score was recorded as six (Eye: 1, Motor: 4, Verbal response: 1). His right pupil was unreactive. Left pupil was reactive. There were no other injuries. CT scan of the brain revealed diffuse petechial haemorrhages, traumatic subarachnoid haemorrhage and non evacuated haematoma.

Figure 3. A forty two year old male with an isolated head injury following an assault.

Initial Glasgow coma score was recorded as four (Eye: 1, Motor: 2, Verbal response: 1). Pupils were small and unreactive. There were no other injuries. CT scan of the brain revealed diffuse petechial haemorrhages, scattered traumatic subarachnoid haemorrhage, obliteration of the basal cistern, non evacuated haematoma and midline shift.

Figure 4. Patient outcome stratified according to injury severity.

The prediction of an unfavourable outcome and the observed outcome for patients with a similar predicted risk (or index of injury severity) in a large cohort of neurotrauma patients who had had a decompressive craniectomy in Western Australia between the years 2004 and 2008 . (Reproduced with kind permission, Mary Ann Liebert, Inc. publisher).