2Department of Pharmacy Services, University of Mississippi Medical Center, Jackson, MS 39216, USA
3Division of Neurosciences Critical Care, University of Mississippi Medical Center, Jackson, MS 39216, USA
Keywords: Role of Palliative Care; Brain Injury; Trauma; Causes of death
A higher incidence of TBI in children aged 0–4 years, adolescents aged 15–19 years, and adults aged 75 years and older compared to other age groups were noted in the Centers for Disease Control report, and the highest rates of deaths from TBI was from adults aged more than 75 years old [5]. Falls (35%), motor vehicle-related injuries (17%), and blows to the head (17%) were reported as the most common causes of non-fatal TBI [9]; while, most of TBI-related deaths were linked to motor vehicle crashed (31.4%) and firearm-related events (34.8%) [10].
The damage from TBI can be immediate (primary) that usually develops from the initial traumatic impact causing; focal brain bleeding, contusion, and bruising or diffuse axonal injury that result from acceleration and deceleration. Secondary injuries occur as an indirect effect of the initial insult which later can lead to brain ischemia and edema, hypoxia, raised intracranial pressure, hypotension, and seizures [6, 11, 12].The severity of TBI is classified into mild, moderate, and severe based on their clinical presentation using the Glasgow Coma score (GCS) where GCS 14-15 is mild and 3-8 is considered severe [11, 13].
Complications from TBI include but are not limited to behavioral dysfunction, seizures, spasticity and multi organ dysfunction, all of which affect their quality of life and functionality. Many patients with severe TBIs will have good outcomes and will be capable of functioning independently, however some may end up with severe disabilities or in a persistent vegetative state, that will require long term care, and will have significant impact on families and care givers producing substantial emotional, behavioral and relationship difficulties [12, 14-17]. Moreover, TBI has major economic implications owing to the hospital care and rehabilitation costs, (direct cost), in addition to the loss of productivity of those patients (indirect cost). Several studies have examined the annual cost of TBI in different countries. In the United stated, the total cost estimate of TBI management ranges from $60 billion up to $76.5 billion [18, 19]. Gustavsson and his colleagues developed a cost model for different brain disorders in about 30 European countries. They found that the direct medical cost of TBI was €5085 million per year [20]. In 2007, a study in Spain found that the economic costs for TBI patient range between USD 1.5 - 5.5 billion annually [21]. In UK, the aggregate cost of TBI was estimated to be £15 billion without including the indirect cost [22]. In Australia, the total indirect and direct costs were estimated to be $8.6 billion with $4.8 billion attributed to severe TBI [23]. A study was done in Ontario, showed that the approximate direct cost of TBI in Canada was $331.1 million in the first follow up year [24].
Because of the severity of illness in TBI patients and its subsequent burden on families, their care during the inpatient and outpatient phases requires an interdisciplinary team approach consistent of rehabilitation and palliative care (PC) services to assist in dealing with the challenges they face during their recovery period [12,25].
Study |
Objective and Study design |
Study population and methodology |
Results |
Remarks |
Traumatic brain injury and palliative care: a retrospective analysis of 49 patients receiving palliative care during 2013-2016 in Turkey. [3] |
Retrospective study to investigate PC requirement, hospitalization period and discharge status of TBI patients in the PC center in Turkey. |
Patients admitted in the PC center of Ankara Ulus State Hospital, Turkey diagnosed with TBI with complete records during the period of 2013-2016 were included. |
-49 patients included in the study |
-Also described trends of variables according to GCS, GOS and KPS |
Palliative Care Consultations in the Neuro-ICU: A Qualitative Study. [29] |
Qualitative study to identify content and themes of PC consultation, analyze the reason for it and describe the most common recommendations of PC specialists. |
Patients admitted from January 1, 2014 who were admitted to the Harborview Medical Center neuro-ICU whose admission was at least 24 hours and who had a PC consultation were included through retrospective EHR review. |
-Included 25 neuro-ICU patients (4.1% of all neuro-ICU admissions from January to August 2014.) |
-Unique study design |
Withdrawal of care: a 10-year perspective at a Level I trauma center. [30] |
Retrospective review of Withdrawal or limitation of care in trauma patients to identify the population of patients undergoing WLC and to describe the process of trauma surgeon -managed WLC. |
Trauma patients admitted from 2000 through 2009 at Scripps Mercy Hospital were reviewed and WLC was determined from the review of the Trauma Medical Director’s dictated death summaries. |
-Among 698 deaths, 375 (53.7%) occurred with WLS |
-first detailed description of the prevalence, clinical presentation and TS-managed process of WLC at an adult Level I trauma center |
Surrogate decision making for patients with severe traumatic brain injury. [31] |
Prospective qualitative study to describe how surrogates made the decision to withdraw or continue life support and whether they believed that health care team could have assisted more during the decision-making process. |
Prospective recruitment of surrogates through the patients’ trauma surgeons or neurosurgeons. Semi structured interviews were conducted with surrogates. |
-10 surrogates agreed to participate up to 11-20 months after the patients’ severe TBI occurred |
-gives a great insight on SDM |
Moderate to severe TBI (msTBI) are one of the most common acute neurological conditions seen in the neurocritical care unit (NCCU) due to its high risk of death with mortality ranging from 12% -61.2% [32,33]. It was also found to be one of the most common diagnosis that entailed specialist PC consultation [34]. The needs of palliative care specifically in the NCCU were mostly for social support and establishing goals of care [34]which are both important in patients with TBI in the ICU especially the geriatric assault patients with TBI who have been found to be sicker with higher mortality and poorer outcomes compared to younger patients [33]. The Improving Palliative Care in the ICU project recommendation to select triggers for PC consultation among critically ill patients include an ICU admission with a hospital stay greater than or equal to 10 days, age more than 80 years old with two or more life-threatening co morbidities (as defined by the Acute Physiology and Chronic Health Evaluation II definitions of severe chronic organ insufficiency), a diagnosis of active stage IV malignancy, status post cardiac arrest; or a diagnosis of intracerebral hemorrhage requiring mechanical ventilation [35-37].
In line with stroke recommendations, neurologists are expected to provide primary PC while in tackling more complex issues, it is recommended to involve specialist PC earlier on [38]. In primary PC, the primary team handles discussions regarding goals of care and prognostication as they manage patients’ symptoms management [39] this level of PC has also been termed as Basic PC [40] Specialty palliative care is an interdisciplinary team that consists of the PC physician, nurse practitioner, nurse, social workers and spiritual providers [38] who are trained and who continue to update their skills and knowledge [40] with regards to providing palliative care.
In Europe, the SDM hierarchy differs between countries. For example, in Belgium, Spain, Switzerland, and Netherlands, if the patient has no SDM, a close relative such as spouse, parents, children or siblings represent the patient. In UK, there are two types of surrogates; a designated power of attorney by the patient and an official representative appointed by the court. However, only the power of attorney can make decisions regarding withdrawal of care, and in case of their absence, it becomes the physician responsibility to make this decision. In Germany, there are similar types of surrogates as in UK, but with equal power, and if there is a disagreement regarding the life sustaining measures, the court’s approval is required [59]. Canada and Australia have similar laws as most countries, where the appointed SDM tops the list followed by relatives in the following order: spouse, child, parent, sibling [60, 61]. In Japan, there is no clear law for SDM. Consents to treat are generally obtained from family members based on the traditional Japanese family structure [61].
Score |
Component |
Remarks |
Glasgow Coma Scale Score [66] |
-assess patient’s responsiveness in terms of Eye, Verbal and Motor responses |
-widely used as an index of brain injury which can be used in estimating prognosis |
Glasgow Coma Scale- Pupil (GCS-P) [67] |
-GCS-P= GCS-PRS, where PRS is the pupil reactivity score |
-outcome 6 months after injury |
SIRS (Systemic Inflammatory Response Syndrome) score [68] |
-SIRS score calculated by assigning 1 point for each SIRS criterion present on admission which include: |
-predictive of length of stay and mortality in trauma patients |
International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) in TBI prognostic model () [69] |
-calculate predictions with complex models |
-based on analysis of multiple clinical trials in traumatic brain injury |
Abbreviated Injury Scale for Head or Neck Regions [70] |
-For the head and neck, Injuries rated 1-6 from minor to major injuries |
-anatomy-based coding system to classify and describe severity of injuries |
Marshall-CT classification (M-CT) [71] |
-classifies patients into 6 CT findings based on intracranial pathology, cisterns presence, midline shift, volume of lesions and lesion evacuation |
-based on 746 patients with severe TBI |
Rotterdam-CT classification (R-CT) [72] |
-includes degree of basal cistern compression, midline shift, presence of epidural hematomas, intraventricular blood and/or subarachnoid blood. |
-predicts mortality at 6 months (Maas AI, Hukkelhoven CW, Marshall LF et-al. Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery. 2006;57 (6): 1173-82) |
Corticosteroid Randomisation After Significant Head Injury trial data (CRASH) model [73] |
-Basic model and CT model |
-similar to IMPACT model, was developed utilizing large datasets |
Medication |
Possible Mechanism of action |
Targeted symptoms |
Dosage |
Available route |
Morphine |
Opiate agonist |
Pain |
Starting dose: intravenous: 1 – 2 mg every 1 – 2 hours as needed |
Intravenous, oral |
Benzodiazepine |
GABA-A agonist |
Anxiety, rigidity, spasticity |
Dependent on specific benzodiazepine |
Intravenous (lorazepam, diazepam, midazolam), oral (lorazepam, diazepam, midazolam, clonazepam), rectal (diazepam) |
Baclofen |
GABA-B agonist |
Spasticity |
Starting dose: 5 mg every 8 hours |
Oral |
Clonidine |
α2-adrenergic agonist |
Hypertension, tachycardia |
Starting dose: 0.1 mg every 8 hours |
Oral, patch |
Propranolol |
Nonselective β-adrenergic antagonist |
Tachycardia, hypertension |
Starting dose: 10 mg every 8 - 12 hours |
Oral |
Bromocriptine |
Dopamine D2 agonist |
Hyperthermia, sweating, hypertension |
Starting dose: 2.5 – 5 mg every 8 hours |
Oral |
Gabapentin |
Voltage-gated calcium channel antagonist |
Pain, spasticity |
Starting dose: 300 mg every 8 hours |
Oral |
The data regarding the effect of palliative care on critically ill patient caregivers is mixed. Some studies showed some benefits to caregivers’ quality of life and satisfaction [91]. Khandewal et al. [91] conducted a systematic review on the effect of palliative care on ICU utilization; they found that patients who received a palliative care intervention had a reduced ICU length of stay, and a decreased rate of ICU admissions [92]. Moreover, it was reported that the quality of end of life care improved with early implementation of don’t resuscitate (DNR) orders, as a result of prolonging the time spent by the patients with their families and loved ones while receiving active palliative care [93]. Over the past few years, there has been a significant increase in the health care expenditure in USA. The introduction of specialized palliative care services in hospitals thought to reduce health care costs by avoiding unnecessary investigations and prolonged ICU/hospital stay [94]. In 2011, a study examined the effect of palliative care consultations on hospital costs for Medicaid beneficiaries in patients with life threatening conditions. They found that hospital costs were less by $6,900 in patients who received a PC consult compared to those received the usual care, with estimated savings of $84 million to $252 million annually in Medicaid’s spending [95].
Recent Studies have empathized the growing needs for palliative care services among patients with neurologic diseases [34, 96]. Interventions provided through palliative care services can play a crucial role in enhancing TBI patients’ and care givers’ quality of life, decision-making, and emotional distress. Furthermore, the expected increase in TBIs rates over the next few years with the concomitant growth of their cost of care requires implementing different strategies to help in reducing the economic burden associated with this condition. It is possible that the early integration of palliative care in the care of these patients could aid in lowering their health care costs and improving outcomes; stemmed from previously published reports on the effect of palliative care on outcomes of critically ill patients [93-95]. Having said that, there is limited data regarding the effect of palliative care on traumatic brain injury patients, and further research is needed to delineate the importance of PC interventions in this specific cohort.
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