Abstract
Background End-of-life (EoL) decisions are routine in neurosurgical care due to frequent devastating
and life-threatening diagnoses. Advance directives, discussions with patients' relatives,
and evaluation of the alleged will of the patient play an increasing important role
in clinical decision-making. Institutional standards, ethical values, different ethnical
backgrounds, and individual physician's experiences influence clinical judgments and
decisions. We hypothesize that the implementation of palliative care in neurosurgical
wards needs optimization. The aim of this study is to identify possible sources of
error and to share our experiences.
Methods This is a retrospective observational analysis. One hundred and sixty-eight patients
who died on a regular neurosurgical ward between 2014 and 2019 were included. Medical
reports were analyzed in detail. A differentiation between consistent and nonconsistent
palliation was made, with consistent palliative care consisting of discontinuation
of medication that was no longer indicated, administration of medication for symptom
control, and consequent discontinuation of nutrition and fluid substitution that went
beyond satisfying hunger or thirst.
Results EoL decisions were made in 127 (84.1%) of all 168 cases; 100 patients were included
in our analysis. Of these patients, only 24 had an advance directive, and the relatives
were included in the communication about the therapy goals in 71 cases. Discontinuation
of medication that is not for symptom control was performed in 63 patients, food withdrawal
in 66 patients, and fluid substitution that went beyond the quenching of thirst was
withdrawn in 27 patients. Thus, consistent palliative care was realized in 25% of
all patients. The mean duration from the EoL decision until death was 2.1 days (range:
0–20 days). If a consistent palliative care was carried out, patients survived significantly
shorter (nonconsistent palliative care: 2.4 days; range: 0–10 days vs. consistent
palliative care: 1.2 days; range: 0–4 days; p = 0.008).
Conclusions The therapy goal should be thoroughly considered and determined at an early stage.
If an EoL decision is reached, consistent palliative care should be carried out in
order to limit suffering of moribund patients.
Keywords
palliative care - traumatic brain injury - neuro-oncology - mortality
