When a decision is made to perform a life saving, but not necessarily restorative, procedure to manage a severe traumatic brain injury, both surgeons and family members face a complicated balance between "acceptable" versus "unacceptable" outcomes. Granting consent to perform such an intervention requires consideration from various points of view: the patient's wishes, implications for the future, and potential clinical complications. More often than not, the patient will not have had an opportunity to express their wishes about surviving an injury severe enough to result in an unacceptable quality of life.
The decision is frequently left to the family members, who must act as a surrogate defender of the position they assume the patient would take. Family members should therefore ask questions about and carefully consider three factors when making a decision.
First, what is the chance of survival with an unacceptable outcome? This can be determined using objective information from studies of patient outcome after life saving interventions such as decompressive craniectomy. Such outcome measures frequently depend on the severity and location of the injury.
Second, what is the cultural, spiritual, and religious orientation of the patient? Here, the individual patient should be considered. Rather than looking only to what the majority of people may want, the family should consider the individual: does the patient feel that life is sacred, or does the patient have a strong feeling that severe disability would be too much of a burden for self and others?
Third, is there a possibility of revisiting these decisions after the potential for a certain outcome becomes more clear? There is always uncertainty about clinical outcomes, but most surgeons would consider certain interventions only if they have determined some reasonable chance of a favorable outcome. Family members can use this information to support deciding for or against the intervention.
Assessing the possibility of an intervention improving the patient's outcome to a life that is considered worthwhile to living, or to one that will be perceived as intolerable and unacceptable, is a difficult process for families to go through. By considering both objective factors from research, as well as knowledge of the individual, family members can focus on a more guided decision-making process.
Honeybul S, Ho K, & Gillett G. Traumatic brain injury: An objective model of consent. Neuroethics. (April 2014).