Neurocritical care
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Surrogate decision-makers ("surrogates") and physicians of incapacitated patients have different views of prognosis and how it should be communicated, but this has not been investigated in neurocritically ill patients. We examined surrogates' communication preferences and physicians' practices during the outcome prognostication for critically ill traumatic brain injury (ciTBI) patients in two level-1 trauma centers and seven academic medical centers in the USA. ⋯ We identified fundamental differences in the communication preferences of prognostic information between ciTBI patient surrogates and physicians. These findings inform the content of a future decision aid for goals-of-care discussions in ciTBI patients. If validated, these findings may have important implications for improving communication practices in the neurointensive care unit independent of whether a formal decision aid is used.
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Case Reports
Ethical and Legal Considerations in the Management of an Unbefriended Patient in a Vegetative State.
Patients without surrogates are referred to as "unbefriended." Because these patients do not have representatives to assist with medical decision-making, patient autonomy and self-determination, fundamental concepts of American healthcare, are jeopardized. ⋯ The unbefriended are one of the most high-risk patient groups. Because our patient had no surrogate with whom we could have a goals-of-care discussion, we were obligated to continue aggressive management despite knowing it would prolong, but not improve, his life. Proactive preventative measures to identify and document end-of-life wishes may make management of these patients less ethically and legally complicated.
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Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this Emergency Neurological Life Support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.