Williams Aaron, Bass Geoffrey D, Hampton Stephen, Klinedinst Rachel, Giacino Joseph T, Fischer David
Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Neurocrit Care. 2024 Oct 15. doi: 10.1007/s12028-024-02143-7.
Disorders of consciousness (DoC) resulting from severe acute brain injuries may prompt clinicians and surrogate decision makers to consider withdrawal of life-sustaining treatment (WLST) if the neurologic prognosis is poor. Recent guidelines suggest, however, that clinicians should avoid definitively concluding a poor prognosis prior to 28 days post injury, as patients may demonstrate neurologic recovery outside the acute time period. This practice may increase the frequency with which clinicians consider the option of delayed WLST (D-WLST), namely, WLST that would occur after hospital discharge, if the patient's recovery trajectory ultimately proves inconsistent with an acceptable quality of life. However acute care clinicians are often uncertain about what D-WLST entails and therefore find it difficult to properly counsel surrogates about this option. Here, we describe practical and theoretical considerations relevant to D-WLST. We first identify post-acute-care facilities to which patients with DoC are likely to be discharged and where D-WLST may be considered. Second, we describe how clinicians and surrogates may determine the appropriate timing of D-WLST. Third, we outline how D-WLST is practically implemented. And finally, we discuss psychosocial barriers to D-WLST, including the regret paradox, in which surrogates of patients who do not recover to meet preestablished goals frequently choose not to ultimately pursue D-WLST. Together, these practical, logistic, and psychosocial factors must be considered when potentially deferring WLST to the post-acute-care setting to optimize neurologic recovery for patients, avoid prolonged undue suffering, and promote informed and shared decision-making between clinicians and surrogates.
严重急性脑损伤导致的意识障碍（DoC）可能促使临床医生和替代决策者在神经预后不佳时考虑撤掉维持生命的治疗（WLST）。然而，最近的指南建议，临床医生应避免在受伤后28天之前就明确判定预后不良，因为患者可能在急性期之后出现神经功能恢复。这种做法可能会增加临床医生考虑延迟撤掉维持生命的治疗（D-WLST）的频率，即如果患者的恢复轨迹最终证明与可接受的生活质量不一致，那么撤掉维持生命的治疗将在出院后进行。然而，急症护理临床医生通常不确定D-WLST需要什么，因此发现很难就这个选项向替代决策者提供恰当的咨询。在此，我们描述与D-WLST相关的实际和理论考量。我们首先确定意识障碍患者可能被转诊至的急性后期护理机构，以及可能考虑进行D-WLST的地方。其次，我们描述临床医生和替代决策者如何确定D-WLST的合适时机。第三，我们概述D-WLST在实际中是如何实施的。最后，我们讨论D-WLST的社会心理障碍，包括遗憾悖论，即未恢复到预定目标的患者的替代决策者常常最终选择不进行D-WLST。在可能将撤掉维持生命的治疗推迟到急性后期护理阶段时，必须综合考虑这些实际、后勤和社会心理因素，以优化患者的神经功能恢复，避免长期不必要的痛苦，并促进临床医生和替代决策者之间的知情和共同决策。
