Tbi

[50960]

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As a medical psychologist working in primary care and with experience working with TBI patients, I am curious about your views on the medical ethics involved with severe TBI patients. I have no agenda, and I know this is a difficult area to comment on. I am simply interested in your opinions on how PM&R docs are currently looking at ethics with this population.

PS.😀 Deanwormer

 

[axm397]

As a medical psychologist working in primary care and with experience working with TBI patients, I am curious about your views on the medical ethics involved with severe TBI patients. I have no agenda, and I know this is a difficult area to comment on. I am simply interested in your opinions on how PM&R docs are currently looking at ethics with this population.

PS.😀 Deanwormer

can you be a little more specific? what aspect of the care of a TBI patient are you talking about?

 

[50960]

To start, how about utilitarian aspects of bioethics. Should a person with a severe TBI who is unlikely to live be given precious medical resources that may be more likely to benfit someone with a lesser injury etc.. I know this is a sticky area, but I am really curious why actual providers in this area think as opposed to academics.

 

[Brooklyndo2.1]

To start, how about utilitarian aspects of bioethics. Should a person with a severe TBI who is unlikely to live be given precious medical resources that may be more likely to benfit someone with a lesser injury etc.. I know this is a sticky area, but I am really curious why actual providers in this area think as opposed to academics.

I am not yet a provider, but it seems to me its all academic until its your kid with a tbi laying there. When one can say that those shoes have been walked in , then that person's opinion might start to be non academic.

just my two cents, and, if im in error, feel free to educate me.

 

[Disciple]

To start, how about utilitarian aspects of bioethics. Should a person with a severe TBI who is unlikely to live be given precious medical resources that may be more likely to benfit someone with a lesser injury etc.

If that's the case the patient is probably still in the neuro ICU. Physiatrists generally aren't involved if death is imminent.

 

[50960]

Yes, I understand that. I am looking more for your opinions, not your practical experience.

 

[axm397]

Yes, I understand that. I am looking more for your opinions, not your practical experience.

but you said you wanted to know how "PM&R docs are currently looking at ethics with this population" - so PM&R relevant TBI topics are NOT whether they should be using resources on severe TBI patients in the acute care setting or not - since we do not take part in the acute management of these patients. When severe TBI patients come to rehab, we usually manage their emergence from there severe TBI - look at Rancho scores, etc. Sometimes there are ethical issues in terms of placement or which family member gets to make medical decisions, etc. Most of our patients already come w feeding tubes, etc. so we do not make those decisions. You might be better off asking neurosurgeons or ER docs about the resource issue.

 

[drusso]

First, as physicians, we are bound to honor our hippocratic oath to do "no harm." As physiatrists, we know that the able-bodied grossly underestimate the quality of life a person can achieve with a significant disability. There is something about "our wiring" that enables us to adapt.

In residency, the common morbid choice me and my fellow residents would pose to one another is, "would you rather be be a complete tretraplegic (non-ventilator dependent) or a severe TBI survivor?" Would you rather move or would you rather think?

Physiatry is about making the best of what is left over. Our tools for prediction are inaccurate. As long as medical resources in this country are *relatively* abundant, then everyone deserves an opportunity to make the best of what is left over...

 

[rehab_sports_dr]

Obviously, the societal use of resources on patients with severe TBI is a contentious issue.

I think a starting point in the discussion is determining what the likelihood of recovery is. I cannot be sure, but reading into your question, it sounds like you are working under the assumption that most patients with severe TBI do not have a good recovery. I don't think that assumption is true

The extent of recovery from even severe TBI is highly variable, and often a good prognosis cannot be made for quite a while after the initial injury.

Second, we are dealing with a moving target. There are new techniques in the management of severe TBI (some are new because they are newly discovered, some are new because they were known but not widely used) that are likely to greatly increase the extent of recovery, including cooling at the time of injury, or the protective use of hormones such as progesterone.

A big issue is that much of what we call severe TBI is a heterogeneous condition, with remarkably different rates of recovery. This is why the Terri Schiavo case was so contentious- the two sides were not in agreement in the extent of her TBI.

So that is the long winded framework for my answer.

In the big picture, it is not clear to me that society should be making a financial committment for more than the base services of healthcare. I think that the care of patients with severe TBI should be considered in the same pool of dialysis in the elderly, ICU management of CHF in the terminally ill, NICU care for premature babies, etc. I am not against the medical care of patients with severe TBI, and I would want it for my loved one, but it is not clear to me that the US government should be paying for it. But at the same time, I am not sure that the US government should be paying for infertility treatments or ICU treatment for a baby born at 29 weeks. In all of these cases, I would want medical care for my loved one if I was in that situation, but that is putting my personal needs ahead of societal needs.

But, if government is going to be paying for these comprehensive medical services, I don't see a reason for severe TBI to be excluded, since the outcomes are not necessarily any worse than it is for these other non-basic health care needs.

 

[Disciple]

Yes, I understand that. I am looking more for your opinions, not your practical experience.

What a Physiatrist contributes to the decision making process is an opinion on what the patient's prognosis for functional recovery and any sort of meaningful life will be (whether the patient is likely to remain in a persistent vegetative state, minimally conscious state, etc.) After that, then my opinion is the same as many others, that the decision to "pull the plug" be decided by the patient's family.