Inter-Physician Variability in Strategies Linked to Treatment Limitations After Severe Traumatic Brain Injury: Proactivity or wait-and-see

BackgroundPrognostic uncertainty is a major challenge for physicians working in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interest arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making in patients with severe traumatic brain injury in the later trauma hospital phase. ResultsA divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team – family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to considering limitations of life-sustaining treatment when the prognosis was grim. They were often the ones who initiated ethical discussions and took leadership in clarification and deliberation processes. They saw themselves as guides for the families and believed both preparation for best-case and worst-case scenarios to be of value. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios. ConclusionsDepending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.Trial registration: Not applicable