Article
Severe Head Injury in Very Old Patients: To Treat or Not to Treat? Results of an Online Questionnaire Distributed to Members of the German Society of Neurosurgery
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Authors
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Claudia Unterhofer
- Universitätsklinik für Neurochirurgie, Innsbruck, Austria
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Sebastian Hartmann
- Innsbruck, Austria
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Martin Ortler
- Innsbruck, Austria
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Christian Freyschlag
- Universitätsklinik für Neurochirurgie, Medizinische Universität Innsbruck, Innsbruck, Austria
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Claudius Thomé
- A.ö. Landeskrankenhaus - Universitätskliniken Innsbruck, Tirol Kliniken GmbH, Universitätsklinik für Neurochirurgie, Innsbruck, Austria
| Published: | June 9, 2017 |
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Outline
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Objective: Increasing life expectancy leads to aging of the population. It remains unclear, which factors influence neurosurgical decision-making when it comes to indications for e.g. evacuation of subdural hematomas in very old patients. Therefore, we aimed to investigate the importance of imaging criteria, patients’ wishes or their next of kin’ wishes and patient demographics on therapeutic decisions made by neurosurgeons.
Methods: An online questionnaire was sent to all neurosurgical units incorporated by the German Society for Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, 9 concerned indication and treatment plan and 4 evaluated the neurosurgeon’s interest in gathering information on the patient’s social circumstances and supposed patient’s wishes or advance directives in case of severe illness.
Results: Of all interviewed neurosurgeons, 85% would perform an emergency operation. Midline shift (84%), hematoma thickness (81%) and the time between traumatic injury and treatment (81%) were considered the most important factors for surgical treatment. Of the respondents 44% responded that they would perform a large osteoplastic craniotomy, whereas 28% of the respondents said they would perform a decompressive craniectomy with duraplasty. Only 13% of the respondents considered a small osteoplastic craniotomy to be sufficient. Monitoring systems would be implanted by 72% of the respondents; especially ICP (intracranial pressure) monitoring would be used by 66%. To gather information on the social circumstances of the patient (66%) and to discuss with family members (57%) was felt to be either less important or unimportant.
Conclusion: Clinical decision making among German neurosurgeons in the case of elderly patients with severe traumatic brain injury is still heavily based on imaging findings. Previous social circumstances and patient wishes seem to be neglected. Thus, we propose an alternative, structured approach that respects the preferences of the patients and their surrogates.
