Study Suggests Waiting Longer Before Withdrawing Life Support for Severe TBI Patients

Lauren Moore, Marketing and Communications Manager, BIAA

When a person is hospitalized for sustaining a severe traumatic brain injury (TBI), their family and loved ones may be faced with the difficult decision to withdraw life support. Families of patients with severe TBI, which by current definition includes a period of unconsciousness, are often asked to make decisions about withdrawal of life-sustaining treatment within days of injury. But a recent study in the Journal of Neurotrauma found that both doctors and patients’ families are likely to make better decisions if they wait even a few days longer than they normally would.

While some doctors would say that patients with severe TBI do not have a strong prognosis, the Journal of Neurotrauma study, which used a national database including 1,392 TBI patients, points out that there is high prognostic uncertainty but growing evidence that recovery of independence is possible.

The study investigated the potential for not only survival, but recovery of independence after acute TBI in patients who died after withdrawal of life-sustaining treatment (WLST) using Transforming Research and Clinical Knowledge in TBI (TRACKTBI) data. The study compared patients with WLST (WLST+) to those with a similar probability of WLST, but whose life-sustaining treatment was not withdrawn (WLST-).

Although 55 percent of the patients whose life-sustaining treatment was continued died in the hospital – typically within about six days – 42 percent who continued life support recovered to the point of having some degree of independence within the following 12 months. Some even resumed their lives prior to their injury.

“Our findings support a more cautious approach to making early decisions on withdrawal of life support,” corresponding author Yelena Bodien of the Department of Neurology’s Center for Neurotechnology and Neurorecovery at Massachusetts General Hospital and of the Spaulding-Harvard Traumatic Brain Injury Model Systems told The Harvard Gazette. “Traumatic brain injury is a chronic condition that requires long-term follow-ups to understand patient outcomes. Delaying decisions regarding life support may be warranted to better identify patients whose condition may improve.”

These results, the study says, suggest a substantial proportion of patients with TBI and WLST may have survived and achieved at least partial independence had life-sustaining treatment not been withdrawn. However, the fact remains that death or severe disability is a common outcome when the probability of WLST is high. Although the study concludes that further research is needed, its findings do support a more cautious clinical approach to WLST and more complete reporting on WLST in TBI studies.

Brent Masel, MD, National Medical Director of the Brain Injury Association of America, said this has always been his approach when talking to family members of patients with severe TBI. “The way I explain this is in terms of a bell-shaped curve,” he explained. While doctors can’t say with any certainty which side of the curve a particular patient will fall on, they can explain what will happen based on where the patient does fall. “I think presenting things in that way to the patients’ families and saying, ‘You know, there are studies that show that if we wait a while longer, they may be, relatively speaking, OK. But there is no way to know.’ I think what families are going to take from this, is perhaps we shouldn’t jump the gun to withdraw life support. Not so quickly.”