Some brain injury patients would recover if life support weren't ended

A substantial proportion of people with a traumatic brain injury who had their life support withdrawn may have survived and at least partially recovered, a study suggests.

Traumatic brain injuries can occur due to a forceful blow, a jolt to the head or an object entering the brain, such as a bullet. Although predicting an individual’s outcome can be difficult, some recover and gain at least partial independence months later. Even so, families are often asked to decide whether or not to withdraw life-sustaining treatment within days of a severe injury.

To learn more about the potential outcomes of such events, Yelena Bodien at Massachusetts General Hospital and her colleagues collected data on people who were on life support following a traumatic brain injury at intensive care units in the US over seven-and-a-half years.

Of these people, 80 had life support withdrawn, and their outcomes were compared with those of 56 people in the same situation who continued with the treatment, some of whom went on to regain a certain level of independence.

The researchers identified factors associated with the withdrawal of life support, such as the person’s age and sex. From this, they used an algorithm to calculate these people’s likelihood of recovery had their treatment been maintained.

These results suggest that 42 per cent of the people who had life support withdrawn may have survived and gained at least partial independence six to 12 months after the injury.

“Prognosis after TBI [traumatic brain injury] is highly uncertain, and expressing this uncertainty to families is very important,” says Bodien. “Our results suggest that a more cautious approach is warranted when establishing prognosis [and that] careful consideration is required when making such an irreversible decision as withdrawal of life-sustaining treatment.”

A lack of information about the long-term outcomes of traumatic brain injury is one reason why making a prognosis is difficult, she says, and this may cause clinicians to assume a poor outcome is probable and therefore recommend withdrawing life support.

Damian Cruse at the University of Birmingham in the UK says the results should be interpreted with some caution. “Decisions to withdraw are multifaceted and don’t necessarily hinge on dichotomies of ‘will they be in a vegetative state or not?’, but are more about whether the level of recovery is something that the patient would have been happy with,” he says.

“That said, it is clear from this and other data that we are not as accurate in our predictions of recovery from the early period after injury as we would like to be, especially as these predictions will feed into families’ difficult choices.”

The researchers would now like to compare recovery rates after a severe traumatic brain injury among people in countries outside of the US, says Bodien.

“We are also conducting studies to understand which statistical methods for imputing outcomes are most precise and could be used in future studies to estimate potential outcomes in patients who die after withdrawal of life support,” she says.