• van Dijck Jeroen T J M JTJM Department of Neurosurgery, University Neurosurgical Center Holland, LUMC-HMC & Haga, Leiden/The Hague., Bartels Ronald H M A RHMA Department of Neurosurgery, Radboud University Medical Center., Lavrijsen Jan C M JCM Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen., Gerard M Ribbers, Kompanje Erwin J O EJO Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands., Wilco C Peul, and all focus group participants.
• Department of Neurosurgery, University Neurosurgical Center Holland, LUMC-HMC & Haga, Leiden/The Hague.
• Curr Opin Crit Care. 2019 Dec 1; 25 (6): 622-629.

Purpose Of ReviewThere is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies.Recent FindingsClinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome.SummaryRecent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.

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