187 Prospective Study of Futile Care in the Neuroscience Intensive Care Unit. (August 2016)

• Record Type: Journal Article
• Authors: Buttrick, Simon; O'Phelan, Kristy; Goodman, Kenneth; Benveniste, Ronald Jay
• Is Part Of: Clinical neurosurgery. Volume 63(2016)Supplement 1
• Publication Date: 2016-08
• Subjects: Nervous system -- Surgery -- Congresses; Neurosurgery; Nervous system -- Surgery; Neurologie; Congresses; Conference papers and proceedings; 617.48
• DOI: 10.1227/01.neu.0000489756.89908.10
• Languages: English
• ISSNs: 0069-4827

Abstract

Abstract : INTRODUCTION: Our health care system spends a significant amount of resources on futile care, ie, continued medical therapy when there is no reasonable hope of cure or benefit. Nowhere is this more evident than in the neuroscience intensive care unit (NSICU), because intensive care medicine has become exceedingly proficient at maintaining cardiopulmonary function even in the face of catastrophic brain injury. METHODS: We identified patients who were admitted to the NSICU with partial loss of brainstem reflexes even after initial stabilization. Sixty-six patients were included and were followed prospectively. RESULTS: At the end of our follow-up period, 47 patients had died. Five patients intermittently followed simple commands but were bedridden, incontinent, and dependent on a tracheostomy. Fourteen were comatose, vegetative, or locked in. In 46 of 66 patients a do not resuscitate (DNR) conversation was documented after an average stay of 5.6 days. In 35 of those cases (76%) proxies agreed to DNR. Average ICU stay was 10.3 days for these patients, compared with 16.7 days for cases in which a DNR discussion was never documented. There was a trend toward higher likelihood of agreeing to DNR with Hispanic proxies compared with white and African American proxies ( P = .058), and for patients with some form of insurance compared with patients with no insurance ( P = .08). CONCLUSION: In our sample of 66 patients with severe brain injury, no patient recovered independence and over two-thirds died. Whenever a DNR discussion was held, there was a high likelihood that the proxies would agree to DNR. These patients spent a significantly shorter time in the ICU, reducing strain on both their families and the health care system. This study demonstrates the importance of having timely, frank DNR discussions with families of patients with devastating brain injuries, and provides evidence that the likelihood of a good outcome in these cases is exceedingly low.