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Table 1 From the Oslo University Hospital local recommendation on sTBI care

From: Neurocritical care physicians’ doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study

Communication with the family
 Identify who is next of kin. Structured family meetings should involve conversations about diagnosis, treatment, prognosis and plan. Repeated updates on patient’s medical status and plans are needed. Strive for continuity of care. Briefings within the team, prior to family meetings, can be helpful in order to develop a common understanding of the situation and be consistent as a team. Always bring the nurse to the briefing and to the family meeting.
Prognostication
 Prognostication involves assessing and communicating what to expect. Prognostic tools in severe brain injury patients have been developed, but are not reliable in individual patients. Individual assessments of prognosis must be made by the interdisciplinary team and must be based on all relevant medical information, both anamnestic, clinical, treatment response. Prognosis in the early stage after a head injury is difficult. Remember reassessments must occur when the condition is more clarified. What are the treatment goals? Are treatment goals realistic? Create a plan for re-evaluation; either time-based or milestone-based. In the most serious injuries, multiple complications may arise, recovery trajectories are long, possible recovery may come late. Cases of persistent disorder of consciousness are rare.
Ethics
 Withdrawal of life-sustaining treatment should only occur after thorough interdisciplinary discussion (preferably during daytime). On duty, preliminary decisions about limitations should be made collaboratively by the anesthetist/ intensivist, the neurosurgeon and the surgical trauma-team leader. See the National ethics guidelines: “Decisions should be based on what is reasonable from a medical and health-related point of view, what is in patient’s best interests and in line with what the patient wants. If there is doubt or uncertainty treatment should be started. Treatment should be continued until its benefit is better clarified. If there is doubt about benefit, the relatives should be informed that treatment might be withdrawn at a later point.” The recognition that treatment is futile or potentially inappropriate may come already in the first evaluation after admittance or become evident later on. When treatment is recognized to be futile and total cessation of intracranial circulation can be expected, the team is obliged to think about donor detection.