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survey found that after 305 resuscitative thoracotomies, 22 (7.2%) different occupational exposures were reported.11 In a separate retrospective study addressing blunt trauma in pediatric patients, it was found that out of 123 thoracotomies, three (2.5%) procedures resulted in occupational exposure. Additionally concerning, the same study found that 63% of the thoracotomies were not indicated. This rate of exposure is more startling when it is considered that 12% of trauma patients receiving thoracotomies in the United States will have an active diagnosis of hepatitis or HIV.12
Many providers recognize that thoracotomies may grant the patients
the opportunity of organ donation. A retrospective review of organ donation after thoracotomies found that out of
organ donors.” Three of these patients, including two blunt trauma patients, donated a total of 11 organs.13 Depending on the transplant capabilities at a trauma center, this may help shape decision- making and family discussions.
The role of a resuscitative thoracotomy in blunt cardiac arrest can be viewed from many ethical positions and as a result, the decision to offer or withhold a thoracotomy is complicated. Still, with respect to futility, we can comfortably offer a discussion of quantitative futility at a mark of <2% survival. Qualitative futility is less clear, but we have seen <2% chance of survival with a “good neurologic outcome.” Even in these
dire situations, it is easy to see how consideration of all factors is incredibly complex. While having the ability to quickly learn a patient’s end-of-life wishes in these moments would be
ideal, instead physicians must rely on experience and limited information in the hope that they are doing what is truly in the patient’s best interest.
CHRONIC FUTILITY
Chronic futility, with respect to trauma, includes providing supportive care
after an acute event that would prolong life but likely never allow a patient to maintain an “acceptable” quality of
life. In daily practice, these situations often introduce unique challenges with goals-of-care discussions. While forms, such as the Delaware Medical Orders
for Scope of Treatment, or the POLST paradigm program, are helpful in setting limitations, patients frequently will leave One area where this is commonly seen in is neurologic trauma.
As the population continues to age
and more individuals are being anticoagulated, traumatic brain injury (TBI) is a growing issue. Survival generally agreed upon. For example, the use of a decompressive craniectomy has been shown to be superior to medical management for intracranial randomly assigned group of patients presenting with TBI and refractory elevated intracranial pressure, surgical intervention had a mortality of 26.9% in 201 patients, compared to 48.9%
in 188 patients treated with medical management. However, with increased survival also comes lower quality of life. The same study found 8.5% of patients treated with surgery survived in a vegetative state, compared to
2.1% of medical patients; and 21.9% of surgical patients remained in a severe level of disability, compared to 14.4% of medically managed patients.14
The ability to guide families through
the decision-making process requires
the ability to offer an early prognosis
in an area with evolving treatment and monitoring, where experts often disagree
scenarios. A survey of Canadian intensivists, neurosurgeons, and neurologists showed that they approached prognostic decisions differently, with >80% using clinical exams and imaging, but <60% using EEGs, and <15% using biomarkers of any kind. In an effort to compare decision-making approaches,
a hypothetical scenario was presented consisting of a 25-year-old male with a TBI and a Glasgow Comma Scale of 6. The experts were split relatively evenly among agreeing, disagreeing, or being undecided on whether this patient would have an “unfavorable outcome at one in obtaining consensus, the same study found that there were no additional details to the scenario that could be added to obtain a 100% agreement
from providers that the scenario was “unfavorable.”15
Since experts cannot agree on overall prognostic factors, some have sought answers from patients. Studies have attempted to ask survivors of TBI if they would retrospectively grant consent for the treatment they received. The major criticism of these surveys is
impaired often cannot respond without the assistance of the friend/family
that made the decision to pursue treatment. This puts the patient in the uncomfortable situation of having to admit to the decision-maker that they may regret their decision which kept them alive. As an alternative approach, studies have asked the opinion of health care providers who care for TBI patients to imagine themselves as the patient for a range of scenarios. When presented with the prognostic probabilities, irrespective of age, religion, and background, the consistent answer is that survival with a severe neurologic disability is, in the words of Honeybul et al., “unacceptable.”16
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