‘give patients with serious brain damage more time to recover’

Every year, more than 5 million people worldwide suffer from severe acquired brain injury (NAH). It is very difficult to predict how things will turn out. Yet the patient’s family sometimes has to make a tough decision in the first days after admission to the hospital. It would be better for them to postpone that for a while, research shows.

If the prospects are very poor, the family will receive as much explanation as possible about the medical situation. The question may then arise whether they want the treatment to continue or whether their loved one should be disconnected from the ventilator. These people rely largely on the judgment of the doctors. However, there are currently no medical guidelines to determine which patients with severe traumatic brain injury have a good chance of recovery, and whose prospects are virtually hopeless.

Postpone decision
Families are often asked to make a decision about stopping treatment within 72 hours after the serious brain injury has occurred. A new study from the American research institution Mass General Brigham shows that it would be better for certain NAH patients if that decision were postponed. The researchers discovered that some patients whose ventilation was stopped had a better chance of survival than thought. These patients may have recovered reasonably well a few months after the brain injury and regain a certain degree of independence.

The researchers came to this conclusion after studying almost 1,400 NAH patients who were treated in the intensive care unit of one of eighteen different American trauma centers over the past eight years. The scientists used a new mathematical model to estimate the chance of discontinuing life-prolonging treatment – based on a variety of demographic data, socio-economic factors, and injury characteristics. They then matched people whose life-prolonging treatment was not stopped with people with comparable model scores, whose treatment was stopped.

Three types of outcomes
You might think that many of the NAH patients who continued treatment showed little or no change after six months, but the opposite turned out to be true. Only a small minority were still in a vegetative state six months after the onset of the brain injury. Most had either died or woke up and recovered with at least some form of independence in their daily activities.

Self fulfilling prophecy
According to the scientists, there is a cyclical, self fulfilling prophecy place: based on previous results, doctors assume that patients have little or no chance of recovery. This assumption leads to the recommendation to stop ventilation, which then increases the risk of poor outcomes. This leads to even more decisions to discontinue treatment.

The team does say that more research is needed with larger groups of patients to understand the many nuances in the recovery pathways for patients with traumatic brain injury.

‘More cautious approach needed’
“Our findings indicate that a more cautious approach is needed when making decisions about withdrawing life support in the first days after brain trauma,” said lead researcher Yelena Bodien of the Massachusetts General Hospital. “Traumatic brain injury is a chronic condition in which the chance of recovery is difficult for the treating physician to estimate. It is important to follow long-term patients who survive. Only in this way can we properly estimate the chances of all possible medical outcomes for the patient. Therefore, in many cases it is a good idea to delay the decision about withdrawing life support. This provides scope to determine which patients have a reasonable chance of an improvement in their medical condition.”