A Decision Aid For High Risk Decision Making In Acute Brain Injury

Challenging conundrums arise in patients with acute severe brain injuries. For these patients, high morbidity interventions such as brain surgery, pharmacologic coma, and prolonged intensive care, have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The relevant clinical knowledge available to guide shared decision-making is constrained to only a limited amount of high quality medical evidence. Furthermore, significant controversy has been ongoing over the interpretation of such evidence with open questions such as: is the mortality benefit from surgery merely a trade-off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the medical literature be communicated to patient-surrogates? How do we incorporate patient values into forming plans of care? The aim of our project would be to develop a decision aid that can assist families and clinicians to make these highly uncertain and risky decisions, in a scientifically informed, unbiased way, and in accordance with individual patient values. We think that insights from Decision Theory, and potentially Expected Utility (EU) theory have been underutilized in medicine, and could be fruitful in improving both communication and decision-making for high-stakes, high-risk clinical scenarios as the ones faced by patients with acute brain injury and their families. Ultimately, the goal is to supplement, and enhance medical shared decision-making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.

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