Page 37 - Deleware Medical Journal - September/October 2019

ETHICS
Beyond survival and profound neurologic disability, even patients with “good” consequences that are often not seen
by the intensivists. There is a much higher rate of Alzheimer’s and chronic encephalopathy as well as late seizures and the development of a psychologic disorder, such as bipolar disorder. The vast majority of patients will return to some form of employment, but it is worth noting that 80% of total costs after a
TBI are related to disability and loss of productivity.17
The decision to sustain a life is often seen as part of the Hippocratic Oath’s injunction to “do no harm.” However, there are long-lasting consequences that must be considered in an effort to avoid placing a patient into a chronically futile situation where the desired outcome will never be reached.
CONCLUSIONS
Futility is an area of heated debate
for good reason. Each aspect of care offers unique decisions that may impact mortality as well as short- and long-term quality of life. The trauma patient offers the additional confounders of acute changes. By the time a prognosis can be patient is hemodynamically stable and the patient or the patient’s family is forced into a discussion of long-term outcomes. As medical and surgical care continues
to progress, we must reevaluate decision- making. Unfortunately, this comes with a mandatory lag while waiting for long-term outcomes research to be available. Most importantly, while we may be able to offer patients overall quantitative mortality data, any qualitative discussion requires family members to understand and respect what each views as an “acceptable” quality of life, and that begins with an open and honest preemptive conversation.
CONTRIBUTING AUTHORS
■ MICHAEL FARRELL, MD, MS, is a 2019 graduate of the general surgery residency program at Christiana Care Health System. He is continuing his training in surgical critical care and trauma/ emergency surgery at the University of California, San Francisco.
■ RAYMOND GREEN, MD, is an acute care trauma surgeon at Christiana Care Health System. He also serves as an Assistant Program Director for the general surgery residency.
REFERENCES
1. Schneiderman L. Defining medical futility and improving medical care. J Bioeth Inq 2011;8:123-131
2. American College of Surgeons Trauma Quality Improvement Program. Palliative care best practice guidelines. Retrieved from https://www.facs.org/quality-programs/ trauma/tqp/center-programs/tqip/best-practice (November 3, 2013).
3. Maerz L, Mosenthal A, Miller R, Cotton B, Kirton O. Futility and the acute care surgeon. J Trauma Acute Care Surgery 2015; 78:1216-1219.
4. Schneiderman L, Jecker N, Jonsen A. Medical futility: its meaning and ethical implications. Ann Int Medicine 1990;112:949-954.
5. Eastern Association for the Surgery of Trauma. Emergency Department Thoracotomy. J Trauma 2015;79(1):159-173
6. American College of Surgeons Committee on Trauma. Practice management guidelines for emergency department thoracotomy. Working Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons-Committee on Trauma. J Am Coll Surg 2001; 193(3):303-309.
7. Endo A, Shiraishi A, Otomo Y, Tomita M, Matsui H, and Murata K. Open-chest versus closed-chest cardiopulmonary resuscitation in blunt trauma: analysis of a nationwide trauma registry. Critical Care 2017;21:169.
8. Suzuki K, Inoue S, Morita S, Watanabe N, Shintani, A et. al. Comparative effectiveness of emergency resuscitative thoracotomy versus closed chest compressions among patients with critical blunt trauma: a nationwide cohort study in Japan. Plos One 2016.
9. Slessor D, Hunter S. To be blunt: are we wasting our time? Emergency department thoracotomy following blunt trauma: A systemic review and meta-analysis. Annals of Emergency Medicine 2015;65(3):297-307.
10. Keller D, Kelp H, Maher Z, Santora TA, Goldberg AJ, Seamon MJ. Life after near death: long-term outcomes of emergency department thoracotomy survivors. J Trauma Acute Care Surgery 2013;74:1315-1320.
11. Nunn A, Prakash P, Inaba K, Escalante A, Majer Z, et al. Occupational exposure during emergency department thoracotomy. J Trauma Acute Care Surgery 2018;85:78-84.
12. Duron V, Burke R, Bliss D, Ford H, Upperman J. Survival of pediatric blunt-trauma patients presenting with no signs of life in the field. J Trauma Acute Care Surgery 2014;77(3).
13. Schnuriger B, Inaba K, Branco B, Salim A, Russell K, et al. Organ donation: An important outcome after resuscitative thoracotomy. JACS 2010;211(4):450-455.
14. Hutchinson P, Timofeev, Czosnyka C, Anderson J, Belli, B, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. NEJM 2016;375:1119-1130.
15. Turgeon A, Lauzier F, Burns K, Meade M, Scales D, et al. Determination of neurologic prognosis and clinical decision-making in adult patients with severe traumatic brain injury: a survey of Canadian intensivists, neurosurgeons, and neurologists. Neuro Critical Care 2013;41:1086-1093.
16. Honeybul S, Gillett G, Ho K. Futility in neurosurgery: a patient-centered approach. Neurosurgery 2013;73:917-922.
17. Stocchetti N, Zanier E. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Critical- Care; 2016.
Del Med J | September/October 2019 | Vol. 91 | No. 5 229