NYMC Faculty Publications

Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of the Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group


Buse Sarigul, Tuzla Public Hospital, Tuzla, Istanbul, Turkey.
Randy S. Bell, Uniformed Services University of Health Sciences, Avera Brain and Spine Institute, Sioux Falls, South Dakota, USA.
Randall Chesnut, Departments of Neurological Surgery and Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, Seattle, Washington, USA.
Sergio Aguilera, Almirante Nef Naval Hospital, Viña del Mar, Chile.
Andras Buki, Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
Giuseppe Citerio, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.
D Jamie Cooper, Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Alfred Hospital, Melbourne, Victoria, Australia.
Ramon Diaz-Arrastia, Department of Neurology, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA.
Michael Diringer, Department of Neurology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
Anthony Figaji, Department of Neurosurgery, Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
Guoyi Gao, Division of Neurotrauma, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
Romergryko G. Geocadin, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Jamshid Ghajar, Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA.
Odette Harris, Brain Trauma Foundation, Palo Alto, California, USA.
Alan Hoffer, University Hospitals of Cleveland, Cleveland, Ohio, USA.
Peter Hutchinson, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
Mathew Joseph, Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India.
Ryan Kitagawa, Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA.
Geoffrey Manley, Department of Neurosurgery, University of California San Francisco, San Francisco General Hospital & Trauma Center, San Francisco, California, USA.
Stephan A. Mayer, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
David K. Menon, Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
Geert Meyfroidt, Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium.
Daniel B. Michael, Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head & Spine Institute, Southfield, Michigan, USA.
Mauro Oddo, Directorate of Innovation and Clinical Research, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
David O. Okonkwo, Departments of Neurological Surgery, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Mayur B. Patel, Critical Illness, Brain Dysfunction, and Survivorship Center; Center for Health Services Research; Tennessee Valley Healthcare System, Veterans Affairs Medical Center; Section of Surgical Sciences, Department of Surgery, Division of Acute Care Surgery Vanderbilt University Medical Center, Nashville, Tennessee.
Claudia Robertson, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
Jeffrey V. Rosenfeld, Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia.
Andres M. Rubiano, INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia.
Juan Sahuquillo, Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain.
Franco Servadei, Department of Neurosurgery, IRCCS Humanitas Research Hospital and Humanitas University, Milano, Italy.
Lori Shutter, Critical Care Medicine, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

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Journal of Neurotrauma

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Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the eattle nternational severe traumatic rain njury onsensus onference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.