New research may help families and doctors make life or death decisions

For neurointensivist and vascular neurologist Julio Chalela, M.D., discussions about traumatic brain injury patients on life support are a challenging but important part of his job at MUSC Health in Charleston, South Carolina. Every conversation with patients’ families about the possible withdrawal or retention of life support measures is based on multiple factors, ranging from medical prognosis to the family’s wishes to what the patient would have wanted.

New research gives Chalela and patients’ families more information to help them make those decisions. The study, out of Mass General Brigham, suggests that some patients with severe traumatic brain injuries who had life support withdrawn might have survived and regained some independence if they’d stayed on life support. 

So while doctors often have the life support conversation within 72 hours of a patient’s arrival, the research may push back that timeline a bit in some cases, Chalela said. “It’s a very interesting study. You know, it challenges our traditional way of thinking where we tend to think that patients with moderate or severe traumatic brain injury usually do very poorly.” 

First, what are traumatic brain injuries?

Simply put, TBIs affect how the brain works. They can be caused by “a bump, blow or jolt to the head,”according to the Centers for Disease Control and Prevention.

The most common cause of TBIs in the Charleston area is falls, whether the patient has fallen at the ground level or from a higher point. Other causes include accidents involving motor vehicles, boats and even golf carts.

TBIs can range from mild to severe. 

• In a mild case, the patient can answer questions and has a clear brain scan.
• Moderate TBIs can cause a concussion, leading the patient to pass out. 

• People with severe TBIs are usually in a coma and/or have a tube inserted to help them breathe.

How does MUSC Health treat TBIs?

Chalela, a professor of Neuro-Critical Care at the Medical University of South Carolina, is part of the team at MUSC Health that treats TBI patients. He and his colleagues stay busy. There are an estimated 190 TBI-related deaths every day in the United States, according to the CDC. 

In best-case scenarios, the trauma team checks out the patient, and the patient goes home. People with mild TBIs can rest and recover with the help of over-the-counter pain relievers. 

 

But some moderate and all severe TBIs are emergencies. Doctors may need to relieve pressure in the skull, remove blood clots, fix fractures, monitor factors such as oxygenation and give the patient medications to help them recover. And in the most severe cases, the patient may require life support.

Those severe situations require the medical teams and patients’ family members to consider whether the patient will recover, and, if they do, what kind of quality of life the person will have. Discussing whether to remove life support is delicate, Chalela said.

“It could be because the situation is dire, and we as physicians don’t think that the patient is going to have a good quality of life. It could be the family stating, ‘My loved one would not want to be on a ventilator for two weeks or three weeks,’ or ‘My loved one wouldn’t want to go to a rehab facility,’ or ‘My loved one wouldn’t want a tracheostomy or feeding tube.’”

Chalela said that can put doctors in a difficult situation, but they put the patients’ and families’ wishes first. “The autonomy of the patient and the autonomy of the family is what matters. You know, we may or may not agree with individual decisions, but we have to respect them.”

The new research

The new research on TBI and life support may help with some of these discussions. 

The reality is that death is inevitable in certain cases – the injuries are just too severe. And many other people with TBIs become permanently disabled. 

But the study suggests that in other cases, leaving TBI patients on life support may let them heal and achieve some independence. They may even be able to get back to their regular lives.

The researchers gave a statement saying that doctors may assume people with TBIs won’t do well, leading to the withdrawal of life support. Their deaths confirm what the doctors believed – that the outlook for such patients is poor. And that triggers more decisions to remove life support.

Chalela said the study is important but not the final word. “The study was not a case-control study. They did not pair cases that had a traumatic brain injury that had care withdrawn and cases where care was not withdrawn and follow them prospectively. That would’ve been the ideal way to do the study. Instead they took patients whose care was withdrawn and inferred what would’ve happened if care hadn’t been withdrawn.”

He said the study does add to a growing body of information about traumatic brain injuries. “But we are still way behind. You know, there’s a lot of ethical, religious, moral and financial factors that can affect family decisions, and the definition of quality of life for every single individual is different."

For now, his takeaway is this: “What this study suggests is that we need to be more cautious when we withdraw care. There’s significant uncertainty in the way we determine prognosis in patients with traumatic brain injury, and we sometimes withdraw care in a very early fashion, and that perhaps we should wait longer before doing that.”