Prehospital care and inhospital trauma care have seen some amazing advances over the last few years. Patients are receiving critical care level interventions not just in the emergency department, but at the point of impact. It is difficult to judge who will benefit from these interventions; patients with traumatic brain injury (TBI) can continue to improve rapidly for six months and then gradually for years after that; those with seemingly unsurvivable injuries can sometimes reach hospital discharge and go on to rehabilitation.
I am often faced with a prehospital dilemma. Should we always provide those interventions? Should we always go all out to save a life? At what cost? My critical care colleagues have said that they are seeing a new type of patient these days – the ‘palliative trauma patient’; those who my colleagues know to have injuries that will ultimately defeat them.
In the past, there was a ‘trial of survival’. If a patient can survive long enough for the ambulance service to reach them, to be extricated from their environment, to be transported to hospital and then receive critical care, they must not be as sick as those who perish outside of the hospital environment and should be more likely to reach discharge. Now there are PHEM docs, and critical care paramedics, and much slicker prehospital ambulance systems with trauma networks, saving a small number of patients in addition who would not otherwise have made it.
It is those few patients that we have trouble defining let alone researching. It is those who we need to be sure we are helping by intervening so early. How many of those patients are leaving hospital neurologically intact? How many are going on to lead fulfilling lives?
Sure, we can extrapolate that the patients who would have survived to hospital will benefit from getting their critical care interventions earlier, we’d love to believe it – assuming that they can be carried out just as well in the prehospital arena as in the ED. But are we helping those who wouldn’t have made it?
Where should the cut-offs be? Age? “Down-time”? Estimated Injury Severity Score (ISS)?
It is rare to have access to a complete medical history, or indeed a truly accurate picture of mechanism, in the few minutes it takes to decide on a plan. Will it be possible to make pragmatic and sensible decisions at the roadside? Or will my colleagues continue to warn us of the epidemic we are bringing to them?
My personal experience of palliative care in trauma could be divided into two types – one where the patient’s comorbidities and functional reserve will limit their chances of survival, and the other where the injuries are not compatible with recovery; most commonly the patient with overwhelming TBI. Both of these types are based on sound histories, examinations and special investigations eg CT scans, etc, all of which take time to collate, digest, and discuss.
Discussion with one’s colleagues and with the patient’s relatives is incredibly helpful when making decisions about end of life care, to get a feel for what the patient would have wanted, to be reassured that more than one person believes in the futility of further curative treatment. The prehospital environment is very isolated, often with one lone specialist practitioner making decisions, so this safety net is taken away.
The suddenness of major trauma mandates an accelerated process of belief and grief in patients’ families, but it still takes time to come to terms with events. Even in the slightly slower time frame of the ED families show signs of denial, and can take a long time to reach acceptance. There is a lower rate of agreement for organ donation in the ED compared with ICU, possibly due to this ‘rushed’ process.
Families want to know that ‘everything was done’ when faced with the news that their loved one is not going to survive or has died. Could it ever be acceptable to say that we predicted futility prehospitally so administered symptom relief with no curative intent?
Of course, there are patients who have died, before prehospital care practitioners even arrive on scene, where we can get a reliable story quickly that too much time has elapsed and resuscitation attempts would be futile, where we feel we can make those decisions.
It may not be possible to get the evidence base we need to create tools to help us with this. If, in the future we can predict with greater accuracy which patients will not survive, and which will benefit from aggressive palliative care, it will not release us from the duty to provide high-level palliative care interventions and help the families in their time of intense emotional stress. We should spend as much effort becoming experts in palliation as we do trauma specialists.