WITHHOLDING CARE IN INTRACEREBRAL HEMORRHAGE: REALISTIC COMPASSION OR SELF-FULFILLING PROPHECY?

WITHHOLDING CARE IN INTRACEREBRAL HEMORRHAGE: REALISTIC COMPASSION OR SELF-FULFILLING PROPHECY? To the Editor: I read the Rabinstein and Diringer editorial with interest.1 Withholding life-sustaining care after severe brain injury due to intracerebral hemorrhage (ICH) is considered by many as compassionate. In discussing the inevitable conclusion that a Do Not Resuscitate (DNR) order leads to a reduction in the level of care and hence more death, it appears that the problem is insoluble. An occasional patient will make a functional recovery after intensive resuscitation and longterm rehabilitation. It cannot be predicted with certainty who that patient will be now or ever. A therapeutic window for neurologic death exists in the first few days after a large ICH, which can be allowed to happen or measures can be taken to prevent it. Once those measures are taken (e.g., surgery, EVD, intubation) the patient will, in many cases, live. Quality of life and functional life are measures that exist on a continuous scale (and not a dichotomous one as we commonly use). What is acceptable for one person may not be for another. Furthermore, not only is the scale continuous, the acceptability to the patient and family may change over time for the patient and/or the caregiver. Thus, even assessing whether the outcome for the surviving patient was “worth it” is challenging. How can physicians provide sensible care in this setting? If all such patients are treated aggressively, how many are we willing to leave alive but bedbound for each who survives to a functional state? What is the allowable number needed to harm? What is the number needed to harm that society can afford? Does it depend upon the age of the patient? I still routinely believe that the worst outcome for a stroke neurologist is to save a life but leave the patient very severely disabled. Health utility scores derived from the stroke victims suggest that being very severely disabled is a fate rated worse than death.2 Yet, if we do not try, we will never improve the fate of patients with ICH. Improved long-term outcome data at 1, 3, and 5 years from stroke may help us reflect better on the acute management. However, with changing mores, improved rehabilitation techniques, and assistive technology such studies will need to be repeated periodically as they will be quickly dated. With such a moving target, we are left to ponder not what we can do, but what we ought to do.