Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review.

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.

Decompressive craniectomy for diffuse cerebral swelling after trauma: long-term outcome and ethical considerations.

BACKGROUND: There is currently much interest in the use of decompressive for the management of diffuse cerebral swelling after trauma. Although the use of the procedure may improve survival, some of those survivors may be left severely disabled. The aim of this study was to see whether severe disability can be predicted and discuss the difficult ethical issue that this raises. METHODS: This was a retrospective cohort subgroup analysis of those patients with severe head injury in Western Australia between 2004 and 2008 who had had a decompressive craniectomy for intractably raised intracranial pressure despite maximal medical management. RESULTS: Among a total of 1,786 adult neurotrauma patients admitted between 2004 and 2008, 74 patients required a bifrontal decompressive craniectomy for intractably raised intracranial pressure. After the application of Corticosteroid Randomization After Significant Head Injury (CRASH) trial collaborators' prediction model, predicted and observed outcomes were compared. The mean timing and median timing of surgery were 42 hours and 30 hours after hospital admission, respectively. The timing of decompressive craniectomy was inversely correlated to the severity of the head injury (Spearman's correlation coefficient = -0.251, p = 0.031). At 18-month follow-up, 16 patients were deceased, 3 were in a persistent vegetative state, and 10 were severely disabled. In contrast to these unfavorable outcomes, 35 patients had a good outcome and 10 were moderately disabled at 18 months. The discrimination of the CRASH prediction model was excellent (area under receiver-operating characteristic curve, 0.905; 95% confidence interval, 0.829-0.982; p = 0.001). CONCLUSION: Our data provide some evidence that the CRASH prediction model may help clinicians and families to make informed decision about the benefits and risks of decompressive craniectomy for diffuse cerebral swelling.

Neurotrauma and the RUB: where tragedy meets ethics and science.

Decompressive craniectomy is a technically straightforward procedure whereby a large section of the cranium is temporarily removed in cases where the intracranial pressure is dangerously high. While its use has been described for a number of conditions, it is increasingly used in the context of severe head injury. As the use of the procedure increases, a significant number of patients may survive a severe head injury who otherwise would have died. Unfortunately some of these patients will be left severely disabled; a condition likened to the RUB, an acronym for the Risk of Unacceptable Badness. Until recently it has been difficult to predict this outcome, however an accurate prediction model has been developed and this has been applied to a large cohort of patients in Western Australia. It is possible to compare the predicted outcome with the observed outcome at 18 months within this cohort. By using predicted and observed outcome data this paper considers the ethical implications in three cases of differing severity of head injury in view of the fact that it is possible to calculate the RUB for each case.

The efficacy of surgical decompression before 24 hours versus 24 to 72 hours in patients with spinal cord injury from T1 to L1--with specific consideration on ethics: a randomized controlled trial.

BACKGROUND: There is no clear evidence that early decompression following spinal cord injury (SCI) improves neurologic outcome. Such information must be obtained from randomized controlled trials (RCTs). To date no large scale RCT has been performed evaluating the timing of surgical decompression in the setting of thoracolumbar spinal cord injury. A concern for many is the ethical dilemma that a delay in surgery may adversely effect neurologic recovery although this has never been conclusively proven. The purpose of this study is to compare the efficacy of early (before 24 hours) verse late (24-72 hours) surgical decompression in terms of neurological improvement in the setting of traumatic thoracolumbar spinal cord injury in a randomized format by independent, trained and blinded examiners. METHODS: In this prospective, randomized clinical trial, 328 selected spinal cord injury patients with traumatic thoracolumbar spinal cord injury are to be randomly assigned to: 1) early surgery (before 24 hours); or 2) late surgery (24-72 hours). A rapid response team and set up is prepared to assist the early treatment for the early decompressive group. Supportive care, i.e. pressure support, immobilization, will be provided on admission to the late decompression group. Patients will be followed for at least 12 months posttrauma. DISCUSSION: This study will hopefully assist in contributing to the question of the efficacy of the timing of surgery in traumatic thoracolumbar SCI. TRIAL REGISTRATION: RCT registration number: ISRCTN61263382.