By Jennifer Popik, JD
This week, a shocking study was published in the Journal of the Canadian Medical Association (CMAJ). The study of six different Canadian trauma centers found that the majority of deaths in patients suffering a traumatic brain injury resulted from the withdrawal of life support, generally within the first three days of ICU admission.
“Our findings are particularly concerning because many decisions to withdraw life-sustaining therapy were made early,” writes Dr. Alexis F. Turgeon et al. “[I]n our study, 64% of patients who died within three days of admission to an ICU had life-sustaining therapy withdrawn. In some instances, this may be too early for accurate neuroprognostication.”
The study, “Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study,” found the removal of life-sustaining therapy was, in large part, due to the physicians’ negative attitude toward the patients’ potential long-term quality of life.
In a commentary published alongside the CMAJ study, Dr. David H. Livingston and Dr. Anne C. Mosenthal put it more obliquely: “Although we attribute the variability in withdrawal of life-sustaining therapy to differences in patient preferences, the article by Turgeon and colleagues adds to the growing body of literature that physician practice and the culture of medical centers may play an equally strong role.”
The study was, in part, prompted by a recent controversy in Canada surrounding the withdrawal of life-sustaining treatment in the context of the ethics of organ donation. While the study focused on Canadian hospitals, the situation in the U.S. is, unfortunately, not significantly better.
In nearly every state, the law (as established by the courts or the legislature) allows someone else to cut off your medical treatment, as well as “artificially” provided food and water, if you cannot speak for yourself and have left no clear expression of your wishes.
This is particularly relevant in cases of traumatic head injury. Not only are these patients unable to make medical decisions, but the CMAJ study shows that doctors increasingly are purposefully focusing on unfavorable prognoses.
The 720 patients that the CMAJ study focused on were NOT brain dead, but in the early days following a traumatic injury.
The study looked at why treatment was being withdrawn so quickly. The most common reason was a poor chance of survival. However, the study suggests that three days might just be too short of a time to conduct proper assessments, understand long-term effects, or even gauge the true extent of the injury which may be masked by swelling and the impact of drugs.
The next most widely cited reason for withdrawal was that families said it was ‘what the person would have wanted.’ This begs the question “how do they know this?”
The final reason is poor long-term prognosis. The authors warn that this sort of negative prognosis from a provider is typically based on the physician’s values.
Because survivors of traumatic brain injuries often carry effects long into life, including disability, the physicians were often inappropriately imposing quality of life judgments when advising families. The authors note, “[T]he impact of traumatic brain injury on quality of life among survivors is tremendous, with up to 30% of patients acquiring major neurologic sequelae [condition resulting from a disease, injury, or other trauma].”
The CMAJ authors add, “This raises the concern that differences in mortality between centres [ranging from 11% to 44%] may be partly due to variation in physicians’ perceptions of long-term prognosis and physicians’ practice patterns for recommending withdrawal of life-sustaining therapy.”
These reasons for denying treatment are so troubling, not only because this is often insufficient time for a medically sound diagnosis, but also because families are under a tremendous amount of stress, only beginning to deal with the traumatic injury. Noting the shortcoming of this kind of reasoning, Turgeon et al. conclude, “Our study highlights the need for high-quality research to better inform decisions to stop life-sustaining treatments for these patients.”
The CMAJ study shows that, more than ever, the provision of health care is changing. It used to be that most physicians, believing in the Hippocratic Oath, generally saw their purpose as saving life. Except in extreme circumstances, they would provide life-saving medical treatment, and they would always give their patients food and water.
It also used to be that courts recognized a presumption for life, and saw their duty as protecting the lives of those who could not speak for themselves. Today, however, many doctors accept a “quality of life” ethic. If they believe someone will have disabilities or have a reduction in their “quality of life” they can attempt to deny life-saving treatment and even food and water to end the person’s life.
In light of this study, it is more important now than ever to talk to your family about your wishes – what treatment you would and would not want. National Right to Life maintains state-specific legal documents that allow you to name someone to make health care decisions for you if you develop a condition that makes it impossible for you to speak for yourself and lets you put into writing what medical treatment you would want if you can no longer speak for yourself. You can find them at: www.nrlc.org/euthanasia/willtolive
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