There are several factors that determine the decisions to withdraw life support treatments in critically ill patients with severe brain injury, says a recent study.

The study, which has been published in the journal of 'Canadian Medical Association Journal,' provides a new understanding of the decision-making processes for this patient population, which accounts for most hospital deaths from trauma. Dr Alexis Turgeon, one of the researchers, said: "Many clinicians struggle to make recommendations to withdraw life-sustaining treatments because decision-making is often complicated by uncertainty from trying to match family or caregiver opinions about what they think the patient would have wanted in terms of quality of life and how well physicians can predict a prognosis."

The death rate in critically ill patients with severe traumatic brain injury is generally high as it occurs after a decision to withdraw life-sustaining treatments. This patient population differs from the general intensive care unit (ICU) population as most patients were healthy before admission to the ICU, as compared with older patients who may already have a poorer quality of life due to pre-existing illness.

Therefore, decisions to withdraw life-sustaining treatments are made differently, mainly based on long-term prognosis and quality of life.
The researchers performed a descriptive qualitative study of interviews with critical care physicians from across Canada to understand the factors that determine a critical care physician's decision to discuss with families the withdrawal of life-sustaining treatments in patients with severe traumatic brain injury.

Results show that several factors are accountable including the patients' pre-expressed wishes and the family's wishes, severity, and location of the injury, along with evidence. Past physician experience, legislation, opinions of colleagues and time are additional factors influencing decisions. The incidence of withdrawal of life-sustaining treatments and of death in critically ill patients with traumatic brain injury varies between hospitals.

Better evidence, tools to help predict patient outcomes, standardisation, better ways to integrate patient values and preferences into decision-making, improved training during critical care fellowships and more time to estimate prognosis are some things that could improve decision-making regarding whether to withdraw life-sustaining treatments.