EDITOR’S MEMORANDUM Coming Up in Neurocritical Care By Eelco F.M Wijdicks, MD, PhD, FNCS, Editor-in-chief More than in any other intensive care unit, The same issue will also publish a paper by Dr. Creutzfeldt and neurointensivists are confronted with colleagues, also fromHarborview Medical Center at the University devastating brain injury resulting in comatose of Washington in Seattle, on prevalence and outcomes of patients patients on a mechanical ventilator. Often, who meet palliative care consultation triggers. This study is a soon after arrival, an initial assessment of retrospective study that looks at commonly identifi ed triggers for futility (or what is now often euphemistically palliative care in the medical intensive care unit in order to see if called disproportionate treatment) can be they could identify the prevalence and type of potential palliative made, particularly if neurosurgery has little to care consultations in a neurosciences ICU. offer. How do we do that, how do we do that with confi dence, and how can we best support The paper does not provide data on palliative care in the families oscillating between anguish and wishful thoughts? neurointensive care unit but identifi es that there are a considerable number of triggers in the neurosciences ICU that suggest palliative I am pleased that the journal Neurocritical Care in August will care is needed. The paper also identifi ed a need to better defi ne publish several important papers on palliative care, the discussion specifi c triggers for neurological critically ill patients, which with family members on patient preferences and surrogate would then lead to a better defi nition of the role of the palliative decision making, and a new position statement for health care consultant in the neurological intensive care unit. Many professionals from the NCS on recommendations for the critical neurointensivists will ask the question whether a palliative care care management of devastating brain injury. These papers are consultation in the neurological intensive care unit is useful, accompanied by an editorial by the accomplished neuroethicist particularly because most neurointensivists spend an inordinate and practicing neurologist, James Bernat. amount of time with family members and built strong rapport in the overwhelming majority of patients with devastating injury. The scientifi c statement on devastating brain injury is largely a summary of prognostication, psychosocial and ethical management The August issue will also include a review article by Dr. Cai problems, and, for the fi rst time, tackles the defi nitional problems and colleagues from the Division of Neurocritical Care and head on. The paper is authored by Dr. Souter and colleagues Emergency Neurology, Department of Neurology, Massachusetts and originated from the Department of Anesthesiology & Pain General Hospital in Boston that clearly reviews the most Management and Neurological Surgery, Harborview Medical Center important issues on patient preferences, advanced care planning at the University of Washington in Seattle. documentation, the defi nition and circumstances of surrogate decision makers, how to proceed with shared decision making The group asked important questions about who should be and the role of physicians in that process, as well as the resuscitated, who should provide consent, what factors identify emotional toll on families. patients at high mortality risk due to brain injury, what are the needs of family members of patients with devastating brain The review paper has an important proposed shared decision injury, and how can clinicians effectively meet the needs of making conference structure that can be used as a template for family members among many other important questions. more effi cient family discussions. Some of the suggestions may Recommendations are provided after an extensive literature seem common sense to many of us, but, for the fi rst time, there review and using GRADE methodology to evaluate the value of is a clear structure for what is perhaps one of the most important the data. Although this paper is preliminary in its assessment, daily tasks of neurointensivists—not to prematurely forego it identifi es major gaps in our knowledge when it comes to the treatments but also not to proceed with indefi nite futile therapies. best assessment of a patient with a devastating brain injury. This In my opinion, there is still a considerable immaturity in dealing is the fi rst paper and will be followed by another manuscript with these important issues. with more specifi c details. The paper is one of the important scientifi c statements that came out of the deliberations of the NCS I hope you will distribute these papers among your colleagues and Guideline Committee. discuss them in journal clubs. The patients’ families expect that from us. 30
224000_NCS_June Currents_2-eMag
To see the actual publication please follow the link above