Ethical Issues in Neuroprognostication after Severe Pediatric 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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2023, Handbook of Clinical NeurologyAssociation between shockable rhythms and long-term outcome after pediatric out-of-hospital cardiac arrest in Rotterdam, the Netherlands: An 18-year observational study
2021, ResuscitationCitation Excerpt :Accurate neurological prognostication in a comatose child after OHCA remains challenging and no international pediatric guidelines exist.21,37,38 Potentially inaccurate prognostication and WLST may bias outcome.28,37,39,40 Third, the median age at time of follow-up was 6.6 years (IQR 3.4–13.4), which is relatively young in childhood and thus growing into deficits might not yet be present.
The current practice regarding neuro-prognostication for comatose children after cardiac arrest differs between and within European PICUs: A survey
2020, European Journal of Paediatric NeurologyCitation Excerpt :It is crucial to predict neurological outcome as accurately as possible in these children in order to discuss further steps of treatment and to inform parents correctly. An inaccurate prediction of long-term outcome could lead to premature withdrawing of life-sustaining treatment (WLST) or at the other end of the spectrum severely disabled children with persistent vegetative state and high impact on resources and caregivers [33]. The aim of our survey was to describe current practices in European PICUs regarding neuro-prognostication in comatose children after CA, in particular, the methods used, their timing, and end-of-life decision making.
Pediatric donation after circulatory determination of death (pDCD): A narrative review
2019, Paediatric Respiratory ReviewsCitation Excerpt :Worldwide, there have been 21 reported cardiac pDCD cases between 2005 and 2014, with a 1-year survival of 61% for DCD vs. 91% for pDBD hearts [25]. Prognostication in general and neuro-prognostication in particular is difficult in severely ill or injured children, and decisions to pursue WLST are never easy [26]. Some critics of pDCD practices contend that either the organ donation organization or pro-donation health care professionals might unduly influence parents or SDMs in order to pursue WLST for the purpose of organ donation [27].