Clinical Course after End-of-Life Decisions on a Neurosurgical Ward: Much to Learn and Improve

Abstract

Background End-of-life (EoL) decisions are routine in neurosurgical care due to frequent devastating and life-threatening diagnoses. Advance directives, discussions with patients' relatives, and evaluation of the alleged will of the patient play an increasing important role in clinical decision-making. Institutional standards, ethical values, different ethnical backgrounds, and individual physician's experiences influence clinical judgments and decisions. We hypothesize that the implementation of palliative care in neurosurgical wards needs optimization. The aim of this study is to identify possible sources of error and to share our experiences.

Methods This is a retrospective observational analysis. One hundred and sixty-eight patients who died on a regular neurosurgical ward between 2014 and 2019 were included. Medical reports were analyzed in detail. A differentiation between consistent and nonconsistent palliation was made, with consistent palliative care consisting of discontinuation of medication that was no longer indicated, administration of medication for symptom control, and consequent discontinuation of nutrition and fluid substitution that went beyond satisfying hunger or thirst.

Results EoL decisions were made in 127 (84.1%) of all 168 cases; 100 patients were included in our analysis. Of these patients, only 24 had an advance directive, and the relatives were included in the communication about the therapy goals in 71 cases. Discontinuation of medication that is not for symptom control was performed in 63 patients, food withdrawal in 66 patients, and fluid substitution that went beyond the quenching of thirst was withdrawn in 27 patients. Thus, consistent palliative care was realized in 25% of all patients. The mean duration from the EoL decision until death was 2.1 days (range: 0–20 days). If a consistent palliative care was carried out, patients survived significantly shorter (nonconsistent palliative care: 2.4 days; range: 0–10 days vs. consistent palliative care: 1.2 days; range: 0–4 days; p = 0.008).

Conclusions The therapy goal should be thoroughly considered and determined at an early stage. If an EoL decision is reached, consistent palliative care should be carried out in order to limit suffering of moribund patients.

Keywords

palliative care - traumatic brain injury - neuro-oncology - mortality

Publication History

Received: 03 October 2022

Accepted: 30 May 2023

Article published online:
03 July 2024

• References

• 1 Schaller C, Kessler M. On the difficulty of neurosurgical end of life decisions. J Med Ethics 2006; 32 (02) 65-69
• 2 Bruera E, Hui D, Dalal S. et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 2013; 31 (01) 111-118
• 3 Raijmakers NJH, van Zuylen L, Costantini M. et al; OPCARE9. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011; 22 (07) 1478-1486
• 4 Côte N, Turgeon AF, Lauzier F. et al. Factors associated with the withdrawal of life-sustaining therapies in patients with severe traumatic brain injury: a multicenter cohort study. Neurocrit Care 2013; 18 (01) 154-160
• 5 Nesseler N, Roquilly A, Lasocki S. et al; BIVILI investigators, ATLANREA group. Patient factors and outcomes associated with the withdrawal or withholding of life-sustaining therapies in mechanically ventilated brain-injured patients: an observational multicentre study. Eur J Anaesthesiol 2018; 35 (07) 511-518
• 6 Geurts M, Macleod MR, van Thiel GJ, van Gijn J, Kappelle LJ, van der Worp HB. End-of-life decisions in patients with severe acute brain injury. Lancet Neurol 2014; 13 (05) 515-524
• 7 Piili RP, Lehto JT, Metsänoja R, Hinkka H, Kellokumpu-Lehtinen PI. Has there been a change in the end-of-life decision-making over the past 16 years?. BMJ Support Palliat Care 2019; bmjspcare-2019 -001802
• 8 Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 2015; 41 (09) 1572-1585
• 9 Eidelman LA, Jakobson DJ, Pizov R, Geber D, Leibovitz L, Sprung CL. Foregoing life-sustaining treatment in an Israeli ICU. Intensive Care Med 1998; 24 (02) 162-166
• 10 Jakobson DJ, Eidelman LA, Worner TM, Oppenheim AE, Pizov R, Sprung CL. Evaluation of changes in forgoing life-sustaining treatment in Israeli ICU patients. Chest 2004; 126 (06) 1969-1973
• 11 Robertsen A, Helseth E, Laake JH, Førde R. Neurocritical care physicians' doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study. Scand J Trauma Resusc Emerg Med 2019; 27 (01) 81
• 12 Neitzke G, Böll B, Burchardi H. et al. Documentation of decisions to withhold or withdraw life-sustaining therapies: recommendation of the Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society for Medical Intensive Care and Emergency Medicine (DGIIN). Med Klin Intensivmed Notf Med 2017; 112 (06) 527-530
• 13 Nelson JE, Bassett R, Boss RD. et al; Improve Palliative Care in the Intensive Care Unit Project. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med 2010; 38 (09) 1765-1772
• 14 Clarke EB, Curtis JR, Luce JM. et al; Robert Wood Johnson Foundation Critical Care End-Of-Life Peer Workgroup Members. Quality indicators for end-of-life care in the intensive care unit. Crit Care Med 2003; 31 (09) 2255-2262
• 15 Nelson JE, Angus DC, Weissfeld LA. et al; Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project. End-of-life care for the critically ill: a national intensive care unit survey. Crit Care Med 2006; 34 (10) 2547-2553
• 16 Baggs JG, Schmitt MH, Prendergast TJ. et al. Who is attending? End-of-life decision making in the intensive care unit. J Palliat Med 2012; 15 (01) 56-62
• 17 Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014; 370 (26) 2506-2514