Introduction: A significant proportion of critical care resources is used to deliver nonbeneficial care, defined as care for patients who have no expectation of recovery. The neuroscience ICU (NICU) represents a particular challenge, as modern critical care medicine has become exceedingly efficient at preserving cardiovascular function, even in the face of devastating neurologic injuries that are certain to lead to death or severe permanent disability.
Methods: We set out to prospectively test the hypothesis that simple criteria can identify patients at high risk of receiving nonbeneficial care early during their illness. Over a 19-month period, all patients admitted to our 24-bed NICU were screened prospectively and included in the study if the following criteria were met: 1) coma with partial loss of brain stem reflexes for >24 hours (excluding cranial nerve deficits from lesions outside the brain), 2) structural lesion of the brain to explain the neurological condition, and 3) absence of medical confounding factors.
Results: A total of 102 patients were included, of which 72 patients died after a mean of 16 days (median: 8 days), and 23 remained either comatose, locked-in, or in a vegetative state. Four were conscious and following commands, while three were minimally conscious, episodically obeying simple commands. Patients who remained full code spent a mean of 22.2 days in the NICU, compared with 10.4 for those who had withdrawal of care (p=0.022), and 11.9 for patients who received a do-not-resuscitate order (p=0.045). Time to death did not differ significantly between the groups. Overall, institution of various limitation of care protocols correlated positively with older age (OR=1.07, p=0.0008), being treated on the neurology service (OR=4.4, p=0.043), and having health insurance (OR=5.4, p=0.03).
Conclusions: We identified simple criteria which can be used to identify patients in the NICU setting for whom continued aggressive care is likely nonbeneficial.
Patient Care: The neurological ICU is a limited and shared resource that needs to be allocated appropriately to maximize the chances of improving the outcome of as many possible patients. By identifying factors that are associated with poor prognosis, providers can have honest discussions with families to make the best decision on how to care for a particular patient.
Learning Objectives: Discuss the importance of goals of care discussions in the neurological ICU and factors associated with poor neurologic outcomes that may be used to guide family discussions regarding goals of care