J Korean Neurosurg Soc.  2014 Apr;55(4):195-199. 10.3340/jkns.2014.55.4.195.

Surgical Decision Making for the Elderly Patients in Severe Head Injuries

• Lee KS
• Shim JJ
• Yoon SM
• Oh JS
• Bae HG
• Doh JW

• KMID: 2191091
• DOI: http://doi.org/10.3340/jkns.2014.55.4.195

Abstract

OBJECTIVE
Age is a strong predictor of mortality in traumatic brain injuries. A surgical decision making is difficult especially for the elderly patients with severe head injuries. We studied so-called 'withholding a life-saving surgery' over a two year period at a university hospital.
METHODS
We collected data from 227 elderly patients. In 35 patients with Glasgow Coma Score 3-8, 28 patients had lesions that required operation. A life-saving surgery was withheld in 15 patients either by doctors and/or the families (Group A). Surgery was performed in 13 patients (Group B). We retrospectively examined the medical records and radiological findings of these 28 patients. We calculated the predicted probability of 6 month mortality (IPM) and 6 month unfavorable outcome (IPU) to compare the result of decision by the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) calculator.
RESULTS
Types of the mass lesion did not affect on the surgical decision making. None of the motor score 1 underwent surgery, while all patients with reactive pupils underwent surgery. Causes of injury or episodes of hypoxia/hypotension might have affected on the decision making, however, their role was not distinct. All patients in the group A died. In the group B, the outcome was unfavorable in 11 of 13 patients. Patients with high IPM or IPU were more common in group A than group B. Wrong decisions brought futile cares.
CONCLUSION
Ethical training and developing decision-making skills are necessary including shared decision making.

Keyword

Prognosis; Decision making; Patient participation; Craniocerebral trauma

MeSH Terms

Aged*
Brain Injuries
Coma
Craniocerebral Trauma*
Decision Making*
Humans
Medical Records
Missions and Missionaries
Mortality
Patient Participation
Prognosis
Pupil
Retrospective Studies

Figure

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  Fig. 1 CT scans of Case 1, 2, and 3. There are acute subdural hematoma with active bleeding (A), traumatic intracerebral hematoma (B), and acute subdural hematoma (C).

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  Fig. 2 CT scans of Case 4. There are bilateral subdural hematomas.

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  Fig. 3 CT scans of Case 5. Acute subdural hematoma was removed by endoscopic evacuation under local anesthesia.

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  Fig. 4 CT scans of Case 6. Acute subdural hematoma was evacuated by decompressive craniectomy.

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