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An Update on Palliative Care in Neurocritical Care: Providing Goal-Concordant Care in the Face of Prognostic Uncertainty

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Abstract

Purpose of review

We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU).

Recent findings

Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient’s prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.

Summary

The uncertainty inherent to both prognosis and patient preferences challenges the provision of goal-concordant care to patients with SABI. The best case/worst case/most likely case scenario is a communication strategy that can aid clinicians when discussing the patient’s uncertain prognosis. A time-limited trial may provide a framework for families and clinicians to pursue aggressive life-sustaining treatment for a certain amount of time, in which prognosis may become more defined, patient goals may become clearer, and clinicians and families may establish a common ground. Although the delivery of goal-concordant care in the Neuro-ICU may be an unachievable, lofty goal, it is a level of care that we should continue to strive for and discuss.

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Funding

National Institutes of Health, R01 NR019268.

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Authors and Affiliations

  1. Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA, USA

    Kristopher A. Hendershot MD

  2. Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA

    Kristopher A. Hendershot MD, Breana L. Taylor MD, Sarah Wahlster MD & Claire J. Creutzfeldt MD

  3. Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, WA, USA

    Maya N. Elias PhD, MA, RN

  4. Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA

    Sarah Wahlster MD

  5. Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA

    Sarah Wahlster MD

  6. Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, 325 9th Avenue, Box 359775, Seattle, WA, 98104-2499, USA

    Claire J. Creutzfeldt MD

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  1. Kristopher A. Hendershot MD
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  2. Maya N. Elias PhD, MA, RN
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Contributions

KAH and CJC were responsible for the preparation and conceptualization of the first draft of the manuscript. All authors contributed equally to the revision of subsequent drafts and approval of the final manuscript.

Corresponding author

Correspondence to Claire J. Creutzfeldt MD.

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Kristopher A. Hendershot declares that he has no conflict of interest. Maya N. Elias declares that she has no conflict of interest. Breana L. Taylor declares that she has no conflict of interest. Sarah Wahlster declares that she has no conflict of interest. Claire J. Creutzfeldt declares that she has no conflict of interest.

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Hendershot, K.A., Elias, M.N., Taylor, B.L. et al. An Update on Palliative Care in Neurocritical Care: Providing Goal-Concordant Care in the Face of Prognostic Uncertainty. Curr Treat Options Neurol 25, 517–529 (2023). https://doi.org/10.1007/s11940-023-00778-z

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