gms | German Medical Science

Objectives: To identify patient factors and disease characteristics including diagnosis, severity of neurological insult, associated injuries/illnesses, co-morbidities, pre-morbid status and quality of documentation.

Methods: Retrospective study of all patients referred to the on-call neurosurgery registrar over a 9 month period (September 2014 to April 2015) in whom neurosurgical intervention was deemed futile.

Results: 100 patients were identified, representing 2.2% of all emergency referrals, most of who were referred by emergency departments (86%). Mean age of patients was 72 (range 16-93). Diagnoses included trauma (31%), spontaneous intracerebral haemorrhage (46%), subarachnoid haemorrhage (11%) and ischaemic stroke (7%). Cardiorespiratory arrest had occurred in 9%. Mode Glasgow Coma Score on referral was 3 (range 3-9, mean 4.5). Unreactive pupils were present in 81%. A significant proportion of patients had been taking anticoagulant (20%) and antiplatelet therapy (29%). Co-morbidities in referred patients included active cancers (10%), dementia (11%), cerebrovascular disease (12%), chronic kidney disease (4%) and ischaemic heart disease (8%). Frailty or non-independent functional status was documented in 19%. Quality of documentation, including reasons why intervention was considered futile, was to a satisfactory standard in 80% and all cases had been discussed with a Consultant Neurosurgeon. Only in 16% was re-referral suggested should the patient improve clinically and these were mainly in patients with poor grade subarachnoid haemorrhage.

Conclusion: This study sheds light on the profile of patients in whom emergency neurosurgical procedures are deemed futile and not in the patients’ best interests. An understanding of this category of patient may lead to better informed decision making by the on call neurosurgical registrar.