Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway.
Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
BMC Med Ethics. 2021 Apr 13;22(1):43. doi: 10.1186/s12910-021-00612-8.
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.
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.
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.
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.
预后不确定性是神经重症监护领域医生面临的挑战。在严重创伤性脑损伤后不同阶段，会出现关于是否继续维持生命治疗是否符合患者最佳利益的问题。缺乏关于医生在不同情况下如何处理伦理问题的深入信息。本研究的目的是深入了解临床医生在处理未解决的预后不确定性方面的策略，以及他们在严重创伤性脑损伤后晚期创伤医院阶段患者出现最小或无神经改善迹象时限制维持生命治疗的伦理推理。
对在挪威一家大型创伤医院神经重症监护病房工作的 18 名医生进行访谈，随后进行定性主题分析，重点关注与限制治疗决策相关的医生策略。
出现了积极主动策略和观望策略之间的分歧。尽管医院有强烈的团队文化，但在伦理推理和首选策略方面，医生之间存在差异。所有医生都强调团队-家庭互动的重要性。然而，他们的策略不同：（1）积极主动的医生在预后不佳时愿意考虑限制维持生命的治疗。他们发起伦理讨论，在目标和选择方面的澄清和审议过程中发挥领导作用，认为自己是家庭的指导者，并相信有必要为最佳情况和最坏情况做好家庭准备。（2）“观望”医生更喜欢开放性治疗（无限制）。他们认为，神经损伤患者需要时间来发现他们真正的恢复潜力。在这个阶段，他们经常避免与家人谈论死亡或其他最坏情况。
根据负责的个别医生，伦理问题可能在晚期创伤医院阶段仍未解决或未得到解决。然而，团队合作有助于减轻医生之间的差异。积极主动和观望方法都存在问题和陷阱。在严重创伤性脑损伤后，最佳利益讨论和治疗限制决策的时机仍然具有挑战性。需要加强与家属及时和公开讨论一系列合理的伦理选择的常规。
