Reply: Neurocritical Care Society Views on "Potentially Inappropriate Treatments in Intensive Care Units".

setting limits and refusing interventions for questions of physiologic futility, but value-laden questions are more likely to provoke dissent. We contend that this supports a stronger position on refusal of therapies based on a physiologic claim, and that a wider distribution of opinions on value-laden questions supports the need of a multidisciplinary review process for such disputes. In considering how this position paper might have different meaning for our neurologic and neurosurgical patient population, we would offer for your consideration how infrequently our disputes over potentially inappropriate therapy are actually related to physiologic concerns. Rather, disputes in neurocritical care units that lead to ethics and palliative care consultation are more often about quality of life. It is not multiorgan failure and the extension of patient suffering that causes our providers to have moral distress; it is the small chance for cognitive recovery and a dignified human existence. As a consequence, an accurate prognosis is paramount in shared medical decision making for our patients. The NCS position paper on devastating brain injury puts a strong emphasis on the limitations of prognostic models in the critically ill neurologic patient and urges a 72-hour observation period before limiting life-sustaining therapy (2). We encourage more research regarding prognosis and the development of improved decision making aids for those with devastating brain injuries. The members of the NCS are most grateful for completion of this landmark policy statement and look forward to the next stage in the discourse of potentially inappropriate treatments. We wholeheartedly agree that the “medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used” (1). n