Ethical Issues in Neuroprognostication after Severe Pediatric Brain Injury

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Neurologic outcome prediction, or neuroprognostication, after severe brain injury in children is a challenging task and has many ethical dimensions. Neurologists and intensivists are frequently asked by families to predict functional recovery after brain injury to help guide medical decision making despite limited outcome data. Using two clinical cases of children with severe brain injury from different mechanisms: hypoxic-ischemic injury secondary to cardiac arrest and traumatic brain injury, this article first addresses the importance of making a correct diagnosis in a child with a disorder of consciousness and then discusses some of the clinical challenges with deducing an accurate and timely outcome prediction. We further explore the ethical obligations of physicians when supporting parental decision making. We highlight the need to focus on how to elicit family values for a brain injured child, how to manage prognostic uncertainty, and how to effectively communicate with families in these challenging situations. We offer guidance for physicians when they have diverging views from families on aggressiveness of care or feel pressured to prognosticate with in a "window of opportunity" for limiting or withdrawing life sustaining therapies. We conclude with a discussion of the potential influence of emerging technologies, specifically advanced functional neuroimaging, on neurologic outcome prediction after severe brain injury

Section snippets

Case 1—Hypoxic-Ischemic Brain Injury Secondary to Cardiac Arrest

A 4-month-old girl with no significant medical history had a cardiac arrest at home. Her parents found her unresponsive, face down in her playpen, and not breathing. She was last seen 20 minutes prior. Her father performed cardiopulmonary resuscitation for 5 minutes and emergency medical personnel continued cardiopulmonary resuscitation (CPR) for an additional 2-3 minutes. Spontaneous circulation returned after a dose of epinephrine. She was intubated and taken to the emergency department,

Case 2—Traumatic Brain Injury

A 2-year-old boy with no significant medical history sustained a traumatic brain injury when a thick tree branch falling from several stories high struck him on the head. He had immediate loss of consciousness but did not have seizures or a cardiac arrest. He was intubated by emergency medical personnel and brought to the emergency department. On the initial examination he was unresponsive to voice and painful stimuli. His right pupil was reactive and his left pupil was dilated with minimal

Making the Correct Diagnosis

The adage often quoted by medical ethicists—“good facts make good ethics”— aptly applies to children after severe brain injury and a disorder of consciousness. Consciousness comprises 2 clinical components—wakefulness and awareness of one’s self and the environment.1 A disordered state of consciousness, which can vary from acute and transient to irreversible and permanent, results when 1 or both of these components are compromised. Disordered states of consciousness are a spectrum of clinical

Deducing an Accurate and Timely Prognosis

The first questions universally asked by family members after a child sustains brain injury are about the probability of survival and the chances for good neurologic recovery. For physicians, generating and communicating an accurate and timely prognosis is essential to establishing the goals of care and directing clinical care. An overly optimistic prediction may result in survival of a neurologically devastated child, whereas an overly pessimistic prediction may lead to withdrawal of

Medical Decision Making After Severe Brain Injury

Parents or guardians are usually the presumed authorized decision makers for their children who have sustained a severe brain insult. Unlike previously competent adults who may have expressed their wishes for what they would want if permanently unconscious, most children have not developed the decision-making capacity necessary to make such choices. Therefore, surrogates cannot use substituted judgment when making decisions for their children. Instead, they are expected to consider what is in

Physician Obligations to Support Parental Decision Making

Physicians have several intertwined ethical obligations in supporting parental decision making while caring for children with acute brain injury. Their obligations are to first communicate, to the best of their ability, the nature of the brain insult, the potential and time frame for neurologic recovery, and their certainty in achieving the predicted functional state. Second and equally as important, physicians must elicit the families’ values and priorities for their child, concerns as

Effect of New Technologies

Emerging technologies, specifically advanced functional neuroimaging modalities such as positron emission tomography and functional MRI are transitioning from the research setting into clinical care and are positioned to have a significant effect on neuroprognostication after severe brain injury.50, 51, 52 These techniques may contribute helpful information to aid in neurologic diagnosis and prognosis, particularly for patients with severe brain insult and a resultant disorder of consciousness.

Conclusions

At the time of the writing of this article, the 4-month old with hypoxic-ischemic brain injury from a cardiac arrest (case 1) is now 6 years old and continues to be followed up at our institution. She has a chronic static encephalopathy and is in a permanent vegetative state. She is severely microcephalic (< third percentile) and opens her eyes spontaneously and to stimulation, but she does not fix on or follow objects. She does not purposefully interact with her environment although she has

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