JAMA ( IF 45.540 ) Pub Date : 2020-01-02 , DOI: 10.1001/jama.2019.19652 Claire J Creutzfeldt,Robert G Holloway
It is estimated that every 3 minutes in the United States, a person dies after sustaining a severe acute brain injury, such as an ischemic stroke, intracranial hemorrhage, traumatic brain injury, or cardiac arrest.1 Almost half of deaths after severe acute brain injury, 100 000 per year, occur during the acute hospitalization, and approximately 90% of patients die after a decision to limit the intensity of treatment rather than from the direct effects of the brain injury.1,2
The decision to continue or withdraw life-sustaining treatment usually involves asking a surrogate decision maker to balance the uncertain possibility that a patient will return to some minimally acceptable quality of life against the burden of a prolonged hospital and rehabilitation course, which are options that are difficult to predict and difficult to fathom.
Prognostic uncertainty may manifest in 2 forms. First, how much will the patient recover? Will he or she walk again? Will he or she talk again? Will he or she be able to think and communicate meaningfully? Second, will the patient come to terms with the new possible disability? Will he or she consider life to have quality? With the aging of the population, advances in acute treatment options, and changing intensive care unit practices, such issues are likely to become more frequent.1,2