Navigating the Thin Line Between Life and Death

Noor F. Shaik, MD, PhDWhen someone is in a coma after a severe injury, how likely is it that they will wake up? If they do, how likely is it that they will recognize their loved ones, talk, or walk again? Neuroprognostication seeks to help answer these extremely difficult questions. Given their complexity, clinicians are encouraged to draw on a range of tools from brain imaging (CT and MRI), blood biomarkers, EEG, and evoked potential testing to help predict the likelihood of neurologic recovery.That estimate often drives life-or-death decisions.For example, after cardiac arrest, the primary cause of death is believed to be neurologic, with people dying from the sequelae of their injuries after withdrawal of life–sustaining treatments (WLST).With so many decisions resting on the neurologic picture, it is striking that most people who experience cardiac arrest never undergo the tests we recommend to build that picture.What We Recommend vs What We DoIn a study of over 1000 patients who had early WLST after out-of-hospital cardiac arrest (OHCA), barely half had undergone head CT, only 22% underwent an additional prognostic test, and a mere 5% had two or more tests. Even when tests are done, they may be inconsistent with recommended practice: An international survey of over 750 critical care and neurology physicians revealed that more than a third used absent corneal or pupillary reflexes at 24 hours, not the recommended 72 hours, for prognostication after cardiac arrest. Because a poor neurologic prognosis drives the majority of decisions to withdraw life support after cardiac arrest, the stakes of getting it wrong are eye-opening. Another analysis of over 4000 OHCA patients used propensity matching to estimate that 16% of those who underwent early WLST (< 72 hours) could have had a favorable neurologic outcome, including being functionally independent.Neuroprognostication is complex and dynamic, and no single test reliably predicts long-term outcomes. When life-or-death decisions are made on the basis of an incomplete or improper assessment, the door to potential recovery is slammed shut.These concerns are not limited to cardiac arrest. In a study of patients with traumatic brain injury (TBI), the 56 who underwent WLST were compared with similar patients who did not. While it was estimated that half of the WLST patients still would have died at 6 months, more than 30% may have recovered at least partial independence.Expertise Matters, but Current Training Falls ShortWhat can be done about this?For one thing, prognostic testing is more common when neurology is consulted. When patients with brain injury receive dedicated neurocritical care, a meta-analysis found that both survival and functional outcomes improved.Yet even neurology trainees and program directors can do better. Prognostication largely lives within neuropalliative care, and a survey of US neurology and residency programs found that 20% of respondents reported no palliative care education and 42% were dissatisfied with what their programs provided. A national survey of neurology residents highlighted discomfort with the uncertainty of neuroprognostication, with residents feeling less prepared with end-of-life than managing stroke. They said they wanted more dedicated experience in palliative care.The flip side is encouraging. When institutions build a structured process, such as a neuroprognostication consultation service, trainees, nurses, and attending physicians reported greater understanding of and satisfaction with neuroprognostication. And greater experience and confidence matter: Senior physicians outperformed junior physicians when predicting functional outcomes after TBI.ConclusionIn my time as a trainee, I came to realize how lucky our patient was to be able to walk into the clinic a year after her cardiac arrest. She was fortunate to have been treated by a neurointensivist who was patient and measured in his approach to neuroprognostication. But her fate should not have been down to luck. If more programs offer dedicated prognostication training, more patients will gain access to the tests that can inform these life-or-death decisions.Noor F. Shaik, MD, PhD, is a vascular neurology fellow at the Hospital of the University of Pennsylvania in Philadelphia. She has published academic research and patient-facing articles on the prevention of and recovery from neurologic injuries, such as stroke and traumatic brain injury. The opinions expressed in this article do not necessarily represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.