Researchers discovered that delaying the withdrawal of life support for patients with severe traumatic brain injuries might result in survival and some regaining of independence, questioning the swift decisions often made based on initial poor prognoses.
Discoveries endorse a more careful approach to making early decisions on withdrawal of life support following traumatic brain injuries.
Severe traumatic brain injury (TBI) is a significant cause of hospitalizations and deaths worldwide, impacting over five million individuals annually. Predicting outcomes after a brain injury can be difficult, yet families are required to decide about continuing or withdrawing life-sustaining treatment shortly after the injury.
In a recent study, Mass General Brigham investigators examined potential clinical outcomes for TBI patients enrolled in the Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study for whom life support was withdrawn. The investigators found that some patients who had life support withdrawn may have survived and regained some level of independence a few months after the injury. These findings indicate that delaying decisions on withdrawing life support may be advantageous for certain patients.
Challenges in Decision-Making for TBI Patients
Families are frequently asked to decide on withdrawing life support measures, such as mechanical breathing, within 72 hours of a brain injury. Information provided by physicians indicating a poor neurologic prognosis is the most common reason families choose to withdraw life support measures. However, there are currently no medical guidelines or precise algorithms to determine which severe TBI patients are likely to recover.
Data Analysis and Findings
Using data gathered over a 7.5-year period on 1,392 TBI patients in intensive care units at 18 United States trauma centers, the researchers established a mathematical model to estimate the likelihood of life-sustaining treatment withdrawal, based on factors such as demographics, socioeconomic status, and injury characteristics. They then matched individuals for whom life-sustaining treatment was not withdrawn (WLST-) to individuals with similar model scores, but for whom life-sustaining treatment was withdrawn (WLST+).
Recovery Potential and the Impact of Premature Withdrawal
Based on follow-up of their WLST- paired counterparts, the projected six-month outcomes for a considerable portion of the WLST+ group were either death or regaining at least some independence in daily activities. Of survivors, over 40 percent of the WLST- group regained at least some independence. Furthermore, the research team determined that remaining in a vegetative state was improbable six months after the injury. Notably, none of the patients who died in this study were declared brain dead, therefore the results do not apply to brain death.
The Self-Fulfilling Prophecy in TBI Treatment
According to the authors, the findings suggest there is a cyclical, self-fulfilling prophecy occurring: Clinicians expect patients to fare poorly based on outcomes data. This expectation leads to the withdrawal of life support, which in turn increases rates of poor outcomes and leads to even more decisions to withdraw life support.
Need for Further Research and Cautious Decision-Making
The authors propose that more research is necessary, involving larger groups of patients, to better match those with and without withdrawal of life-sustaining treatment (WLST) in order to understand the different paths to recovery for patients who suffer from traumatic brain injuries.
Yelena Bodien, PhD, the corresponding author from the Department of Neurology’s Center for Neurotechnology and Neurorecovery at Massachusetts General Hospital and the Spaulding-Harvard Traumatic Brain Injury Model Systems, stated that the research findings support a more careful approach to deciding when to withdraw life support early. Bodien suggests that traumatic brain injuries are long-term conditions that require ongoing monitoring to fully comprehend patient outcomes, and delaying decisions on life support may help identify patients who could improve.
Reference: “Recovery potential in patients who died after withdrawal of life-sustaining treatment: A TRACK-TBI propensity score analysis” 13 May 2024, Journal of Neurotrauma.
