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May #NCSTJC Wrap-Up

By Currents Editor posted 20 days ago

  

Brooke Barlow, PharmD (@TheABofPharmC); Eric C. Lawson, MD (@EricLawson90)

#NCSTJC Moderators: @drdangayach @tchaaban1
Authors: @SWahlster @cj_creutzfeldt @jgranstein
#NCSTJC Twitter Thread: https://twitter.com/i/events/1526241410856402944?s=20

Welcome to the #NCSTJC Round-up! May’s NCS Twitter Journal Club featured a lively discussion on the article, “Taking a Chance to Recover: Families Look Back on the Decision to Pursue Tracheostomy in Severe Brain Injury” by William Lou et al published in Neurocritical Care

This was a single-center, qualitative study that assessed the long-term reflections of patients and their families on the decision to pursue tracheostomy after severe acute brain injury. Patients and families of severe brain injury survivors were invited to participate in a telephone interview at 3 months after the injury. The authors concluded “After severe acute brain injury, prognostic uncertainty almost transcends the concept of choice. Families who proceeded with a tracheostomy saw it as the only option at the time. High-quality communication may mitigate the stress surrounding this high-stakes decision.” 

An engaging discussion was held on the Twitterverse regarding the important findings of this study and below we will review some of the conclusions and key points from the #NCSTJC. 

Most respondents emphasized the importance of the crucial conversation on prognosis/ prognostic uncertainty with loved ones and ensuring they have a good understanding of what life with a tracheostomy entails. Social support, family expectations, and access to/availability of chronic care centers were other important factors considered in the conversations with the next of kin. 

A common theme throughout this question was the importance of using terms easy/clear to ensure family members understand and acknowledging uncertainty in the patients’ trajectory. @ZachThrelkeldMD stated “I wish that I had a crystal ball and could tell you exactly what the future looks like, but I do not. But I can tell you about what I think the best possible, most likely, and worst possible outcomes might look like." Similarly, author @SWahlster stated “Acknowledging the uncertainty early on in an honest, transparent manner while giving all the information we do have is important in building trust and preparing the family for what’s ahead.” Several other comments reflected these statements in ensuring family members are informed of all possible trajectories before making a decision.

All participants who responded commented on wondering about their patient’s trajectory months and even years after their intensive care unit stay. Furthermore, participants emphasized the importance of patient/family member follow up to understand their journeys and how they can best support them along recovery process. @EderCaceres5 commented “Yes! I’ve seen patients 6mo and 1 yr after injury. For worst cases family is sometimes worn out and fearful of future. But there are also cases of recovery and gratitude. I don’t think there is an absolute answer.” 

@EderCaceres5 commented “It means listening to the family without pressure, their expectations, fears, doubts, social factors and support. Then explain the situation in an honest and objective way and making the most reasonable decision together.” Other responses mentioned creating an atmosphere of mutual respect and trust among patients and providers, listening to the family, their goals and values and ensuring families understand there is no “right or wrong” answer as the decision to pursue tracheostomy is an individualized one. 

@EricLawson90 commented “I think its a combination of all of these factors. So important to try to give families a picture of what the road ahead looks like, while also charting a course for realistic goals for that individual patient. #NCSTJC”. The Results of the poll demonstrate a large portion of respondents indicated patient function prior to injury, and psychosocial support as large factors that help them frame conversations regarding tracheostomy with next of kin.

The general census to timing of tracheostomy discussion was the importance of not delaying the discussion, the earlier the better. However, it was also noted that “it depends” based on the severity of the brain injury and the other complications/comorbidities the patient was experiencing during their acute critical illness.  

The May #NSCTJC fostered a fantastic discussion on the crucial conversations surrounding the patient and family member conversations and reflections on tracheostomy placement after severe acute brain injury. The discussion highlighted the vital importance of clear communication with family regarding patient prognosis and listening to patients/family members goals, values, and expectations to engage in shared decision making to ultimately decide on the best decision for the patient.  

Access the full article here: http://rdcu.be/cMhJr

#NCSRoundup

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