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Intersection of prognosis and palliation in neurocritical care

Rubin, Michael; Bonomo, Jordan; Hemphill, J. Claude III

Current Opinion in Critical Care: April 2017 - Volume 23 - Issue 2 - p 134–139
doi: 10.1097/MCC.0000000000000396
NEUROSCIENCE: Edited by Raimund Helbok

Purpose of review Difficult discussions regarding end-of-life care are common in neurocritical care. Because of a patient's neurological impairment, decisions regarding continuing or limiting aggressive care must often be made by patients’ families in conjunction with medical providers. This review provides perspective on three major aspects of this circumstance: prognostication, family–physician discussions, and determination of death (specifically as it impacts on organ donation).

Recent findings Numerous studies have now demonstrated that prediction models developed from populations of brain-injured patients may be misleading when applied to individual patients. Early care limitations may lead to the self-fulfilling prophecy of poor outcomes because of care decisions rather than disease course. A shared decision-making approach that emphasizes transmission of information and trust between families and medical providers is ethically appropriate in severely brain-injured patients and as part of the transition to end-of-life palliative care. Standard definitions of death by neurological criteria exist, although worldwide variation and the relationship to organ donation make this complex.

Summary End-of-life care in patients with severe brain injuries is common and represents a complex intersection of prognostication, family communication, and decision-making. Skills to optimize this should be emphasized in neurocritical care providers.

aDepartment of Neurology and Neurotherapeutics; Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas

bDepartments of Emergency Medicine, Neurosurgery, and Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio

cDepartment of Neurology, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA

Correspondence to J. Claude Hemphill III, MD, MAS, Department of Neurology, Building 1, Room 101 San Francisco General Hospital, 1001 Potrero Avenue San Francisco, CA 94939, USA. Tel: +1 415 206 3213; e-mail:

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