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Chapter 35. Ethics and Professionalism

A 51-year-old woman with known history of hypertension and diabetes is brought to the emergency department (ED) after collapsing at a local restaurant while dinning with her family. She was found pulseless, and cardiopulmonary resuscitation (CPR) was started at the scene and continued by emergency medical services (EMS) while being transported to the ED where she has return of spontaneous circulation. Her “down time” was estimated to be around 15 minutes. She is minimally responsive to verbal stimulation, and cranial nerve exam shows no deficit. Computed tomography (CT) scan of the head on the first day shows possible decreased gray/white matter differentiation, but the findings are not definitive. Electroencephalogram (EEG) is pending. Which of the following is correct regarding neurologic prognostication in this patient?

A. The patient’s exam at presentation will be no different than her exam after the first week.

B. Lack of any cranial nerve deficit indicates that the patient will have a functional recovery.

C. The family should be encouraged to wait at least 72 hours before withdrawing life-sustaining therapy as the exam may improve.

D. A unilateral do not resuscitate (DNR) order is appropriate.

E. Magnetic resonance imaging (MRI) is needed before any proper evaluation of neurologic recovery can be made.

C. Neurologic prognostication after catastrophic brain injury should be postponed until at least 72 hours from the injury. It is recommended by the Neurocritical Care Society guidelines that such evaluation be based on repeated examinations over time to establish increased accuracy and that treatment should be directed to maintain physiologic stability and avoid deterioration to allow sufficient opportunity for prognostic evaluation. The society recommends using a 72-hour observation period to determine clinical response and delaying decisions regarding withdrawal of life-sustaining treatment in the interim. Exceptions can of course be made, if, for example, the patient would have preferred to have been DNR before being resuscitated by medical providers who are not aware of a previously established patient preference of advance directives.

A 61-year-old man is admitted to the intensive care unit (ICU) after a large left middle cerebral artery (MCA) stroke. He is intubated, comatose, and has a hemiparesis. The patient has notable brain atrophy secondary to chronic drug abuse and is not showing signs of herniation despite cerebral edema. The family informs you that he would not want to live in this condition and asks what his chances are of recovery to a “near normal life.” After reviewing his case, you determine that his expected recovery to an independent state is unlikely. The family brings up the fact that he wanted to be an organ donor and is on ...

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