Neuroprognosis. A scholarly and soulless word to actually describe an infinitely sensitive “concern”, both from a medical and ethical point of view: to provide the relatives of a person in intensive care with the most “accurate” prognosis possible concerning his chances of neurological recovery.
A very familiar situation for Dr Pierre-Marie Bertrand, head of the Intensive Medicine Resuscitation department at the Cannes Simone Veil hospital. If this specialist, at the forefront of neuroprognosis, is delighted that his service now has a new technology allowing to carry out an electroencephalographic examination 24 hours a day and 7 days a week, allowing to improve the neuroprognosis (1) , it is the substantive issues surrounding this approach that he wishes to address.
The risk of a falsely pessimistic or optimistic diagnosis
“At this stage of knowledge, nothing allows us to affirm 100% that a person whose brain, for various reasons, has suffered, will more or less recover his autonomy. However, it is fundamental that this neurological prognosis be reliable, because the consequences are major. A falsely pessimistic prognosis can indeed lead to a LAT (Limitations and Stops of Treatments, Editor’s note) and therefore to the death of patients who actually have a hope of neurological recovery. falsely optimistic diagnosis encourages continuing resuscitation at the cost of very serious neurological sequelae in patients who would not have wanted it.” And the doctor recognizes that certain situations “favor” unreasonable obstinacy: “The temptation is strong, when we find ourselves in particular in front of young patients, to say to ourselves: “it’s too unfair, we have to continue treatment at all costs.“” At the risk of going too far.
What is acceptable?
In other words, to artificially keep alive a patient whose neurological state is very seriously altered. “To no longer be aware of your life, of that of others, is that acceptable?”, asks the resuscitator. And immediately, he counterbalances: “On the other hand, doesn’t life deserve to be saved, when, despite significant sequelae, a social bond is maintained, allowing access to moments of happiness? These questions must be discussed frankly with loved ones, it is essential.”
Try not to be guided by emotion alone, but to rely more on reason.
If there remains a gray area in neuroprognosis, which gives rise to these ethical questions, specialists fortunately benefit from tools that help them establish the most reliable neuroprognosis possible. “We use a combination of predictors: clinical neurological examination of course, electro-physiological explorations, dosage of serum biomarkers – this is fundamental –, and above all neuroimaging by MRI. The continuous electroencephalogram (EEG), which makes it possible to continuously monitor the evolution of the patients is also a plus that completes this arsenal.”
An arsenal that provides the fastest possible response to families anxiously awaiting awakening. “Prolonged uncertainty and lack of response are factors that aggravate the state of post-traumatic stress experienced by a third of the families or relatives of patients hospitalized in intensive care.”
Together to respond to complex situations
A major fact in the Alpes-Maritimes department and in Eastern Paca, the resuscitation services are closely linked. And when the question “should we stop or continue the treatments?” arises within a service confronted with a patient whose prognosis remains very uncertain, the most expert resuscitators in neuroprognosis are “seized” to give their opinion.
“The patient’s wishes, when they are known to relatives, are essential and help us in decision-making. But these situations remain very complex. Because if for most of us, disability is prohibitive – “I would rather die than live with a disability”when faced with a serious illness, it is a very different position that is often expressed: “The value of life then takes on enormous importance. When patients wake up from a coma, all have a very strong momentum of life.”
A conclusion that should not be interpreted as: “life at all costs” – “Those days are over, and so is medical paternalism.”
1. The CHC-SV recently equipped the Intensive Medicine Resuscitation department with innovative technology making it capable of carrying out an electroencephalographic examination 24 hours a day, 7 days a week and thus providing a reliable neurological prognosis within 24 hours.
Cardio-respiratory arrests in the foreground
The numbers speak for themselves. Cardio-respiratory arrests in the Provence Alpes Côte d’Azur region are responsible for 33.6 deaths per 100,000 inhabitants. It is also a significant part of the activity of Critical Care services.
“About 80% of patients admitted to an intensive care unit after resuscitation from out-of-hospital cardiac arrest present with a coma on admission, and two-thirds of them die from anoxic-ischemic brain injury. (LCAI). However, only a minority of deaths are the direct consequence of these lesions. Most of them result from a decision to limit or stop treatment (LAT) linked to a pejorative neuro-prognosis.”reports Dr. Bertrand.
We know that a cardiac arrest lasting more than 5-6 minutes without any resuscitation causes brain damage which will result, if the patient survives, in the appearance of serious sequelae: memory impairment, syndrome parkinsonian, epilepsy, more or less significant loss of sight, confusional or even insane syndromes…
Professor Jean-Christophe Orban, anesthetist-resuscitator and head of the Anesthesia and Critical Care Unit of the University Hospital of Nice, in collaboration with other resuscitators in the region, has been conducting studies for years on the prognosis of patients who have suffered cardiac arrest. and who are still in a coma three days later.
“Families ask us: will he (she) wake up? It is very difficult to answer this question. Families must be explained that cardiac arrest is a brain problem. arrested, but it is the brain that has suffered the most from this arrest. What are the consequences? We cannot give a definitive answer: in intensive care there is always a gray area or an area of uncertainty. And the biological markers , such as the NSE (Specific neuron enolase) or lactate, a marker of hypoxia, if they alone cannot provide an answer, are a valuable aid: thanks to them, and to the EEG, we can tell patients families: it’s a good prognosis, we are rather confident or we are not.”