Experience in Rehabilitation Medicine Affects Prognosis and End-of-Life Decision-Making of Neurologists: A Case-Based Survey

Abstract

Background: Outcome predictions in patients with acute severe neurologic disorders are difficult and influenced by multiple factors. Since the decision for and the extent of life-sustaining therapies are based on the estimated prognosis, it is vital to understand which factors influence such estimates. This study examined whether previous professional experience with rehabilitation medicine influences physician decision-making.

Methods: A case vignette presenting a typical patient with an extensive brain stem infarction was developed and distributed online to clinical neurologists. Questions focused on prognosis, interpretation of an advanced directive, whether to withdraw life-sustaining treatments and information on prior rehabilitation experience from the survey respondent.

Results: Of the participating neurologists, 77% opted for the withdrawal of life-sustaining therapies (n = 70; response rate: 14.8%). This decision was not affected by age, gender, or length of clinical experience. Neurologists with experience in rehabilitation medicine tended to estimate a more positive prognosis than neurologists without, but this result was not significant (p = .13). There was an association between the intervention chosen and previous experience in rehabilitation; neurologists with experience in rehabilitation medicine opted significantly more often (31.8%) for continuing life-sustaining treatments than neurologists without such experience (8.7%, p = .04).

Conclusion: Our results indicate that there are subjective factors influencing decisions to limit life-sustaining treatments that are based on previous professional experience. This finding emphasizes the variability and cognitive bias of such decision processes and should be integrated into future guidelines for specialist training on end-of-life decision-making.

Keywords: Disorder of consciousness; End-of-life decision; Life-sustaining therapy; Neurointensive care; Prognosis; Stroke.

Fig. 1

MRI scan of fictional patient Mr. M. presenting defects following a basilar artery embolism as part of a case vignette aimed at neurologists

Fig. 2

Neurologists individual response frequencies on probability to regain consciousness and ability to communicate (Question 1, see Table 1) on a Likert like scale from 1 = unlikely/very uncertain to 10 = likely/very certain

Fig. 3

Neurologists individual response frequencies on confidence in their prognostic estimate (Question 2, see Table 1) on a Likert like scale from 1 = unlikely/very uncertain to 10 = likely/very certain

Fig. 4

Comparison of estimated prognosis in neurologists with vs. without rehabilitation experience