It is recognised that accurate prognostication in life threatening brain injury is difficult, particularly at an early stage. The eventual outcome for such patients is often death or survival with severe disability. Many consider that admitting such patients to the Critical Care Uniti has little to offer in the absence of a therapeutic option, or that admission is inappropriate because it prolongs the dying process and is wasteful of precious resources. Therefore in these circumstances withdrawal of life sustaining treatments (WLST) is common practice and considered justifiable.
A UK neurosciences ICU which sought to change current practice by admitting this patient cohort for observation, primarily to aid prognostication, has recently published their experience. This has confirmed in a UK context what many intensivists, neurologists and neurosurgeons already accept; that occasionally patients go on to make a good recovery despite very poor early prognostic signs.
Without controlled studies the evidence to guide decision making will be weak when compared with other interventions in critical care. Such studies are unlikely and the risk of a ‘self-fulfilling prophecy’, with early prognostication leading to early WLST and death, continues to exist. Case series and the development of appropriate registries can be helpful in increasing the evidence base. Evidence based guidelines as constructed by agreed GRADE criteria in such circumstances will often lead to weak recommendations. Nonetheless the Neurocritical Care Society in the United States has recently undertaken a systematic review and made several recommendations3 that have helped inform this consensus statement. The Joint Standards Committee of Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) recognises that the weak evidence base makes the development of guidelines and protocols difficult to justify, but believes that guidance in this area would help practicing clinicians deliver safe, effective, equitable and justifiable care within a resource constrained NHS. The Joint Standards Committee therefore convened a consensus group with representation from stakeholder professional organisations to produce this guidance.
This statement is intended to help consultants when making decisions on the management of patients admitted with a perceived devastating brain injury (DBI), and should not replace their clinical judgment.
