Outcomes of the first full year of implementing a devastating brain injury pathway

Since the original online publication of our article “A Case for Stopping the Early Withdrawal of Life Sustaining Therapies in Patients with Devastating Brain Injuries” ¹ in JICS, we are able to provide an update on the first full year of implementation of the devastating brain injury (DBI) pathway at Southmead Hospital, Bristol. Between July 2015 and June 2016:

21 patients were admitted to the intensive care unit (ICU) instead of undergoing withdrawal of life-sustaining treatment (WLST) in emergency department;

Five patients had the treatment limitation decision reversed and treated actively;

Three patients survived – two cognitively intact and one still in rehabilitation;

Other 16 patients died, all within 48 h of admission;

End-of-life care enhanced in all patients;

Thirteen relatives approached for organ donation; twelve consented (92%);

Five became actual donation after brain death donors and two actual donation after cardiac death donors.

The number of patients admitted (21) to our neurosciences ICU in one year suggests that such a pathway should not overwhelm ICU-bed capacity for many general ICUs. The pathway has met all the stated aims of its introduction in that postponing the decision to withdraw life-sustaining treatments has resulted in unexpected survivors, has enhanced end-of-life care, and has given families the option of organ donation when there was this possibility in meeting their dying relative’s wishes.

The number of patients admitted is small and it is difficult to reach firm conclusions based on the experience of one neurosciences ICU. However, they may give some insight into what might be achieved if such pathways were more widespread. A simple calculation of the number needed to treat (NNT) and number needed to harm can provide such insight. The NNT (or the number of ICU admissions in the DBI pathway) to achieve one survivor is 7. The NNT to reverse a decision to WLST and treat actively is 4. The NNT to successfully facilitate one actual organ donation is 3. The NNH to result in one survivor with a potentially poor neurological outcome is 21. The NNH to result in one potential survivor with a good outcome not being treated to avoid one survivor with a poor outcome is 2. Finally, the 92% consent rate to organ donation from the families of these patients compares favourably to the national consent rate of 61%. ² This in itself suggests that families of these patients are appreciative of the end-of-life care provided.

We understand that these numbers are too small to address the legitimate concerns of intensivists, but perhaps the time has come for guidance from our professional bodies on this issue. There is also a need for development of appropriate audit tools to accurately identify patients admitted to ICU as part of a DBI pathway, both to improve outcome data and also to remove disincentives to ICUs and neurosurgeons from adopting such pathways for fear of its impact on an individual clinician’s or institutions’ standardised mortality ratios.