Inter-Physician Variability in Strategies Linked to Treatment Limitations After Severe Traumatic Brain Injury: Proactivity or wait-and-see
Autor: | Reidun Førde, Eirik Helseth, Annette Robertsen |
---|---|
Rok vydání: | 2020 |
Předmět: |
Health (social science)
Critical Care Medical philosophy. Medical ethics Traumatic brain injury media_common.quotation_subject Decision Making Best interests 03 medical and health sciences 0302 clinical medicine Nursing Physicians Intensive care Brain Injuries Traumatic medicine Humans 030212 general & internal medicine Qualitative Research Severe traumatic brain injury Persistent vegetative state media_common Ethics Disorders of consciousness R723-726 Norway Health Policy Proactivity medicine.disease Deliberation Futile treatment Issues ethics and legal aspects Philosophy of medicine Thematic analysis Psychology Medical Futility 030217 neurology & neurosurgery Research Article Decision-making |
Zdroj: | BMC Medical Ethics BMC Medical Ethics, Vol 22, Iss 1, Pp 1-9 (2021) |
Popis: | Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened. |
Databáze: | OpenAIRE |
Externí odkaz: |