Neurocritical Care

, Volume 23, Issue 1, pp 4–13 | Cite as

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

A Position Statement for Healthcare Professionals from the Neurocritical Care Society
  • Michael J. SouterEmail author
  • Patricia A. Blissitt
  • Sandralee Blosser
  • Jordan Bonomo
  • David Greer
  • Draga Jichici
  • Dea Mahanes
  • Evie G. Marcolini
  • Charles Miller
  • Kiranpal Sangha
  • Susan Yeager
Review Article


Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.


Devastating brain injury Critical care management Neurocritical care Evidence Guidelines Recommendations GRADE 


Conflicts of interest

Michael J. Souter has received salary support paid to the University of Washington as Medical Director, Lifecenter Northwest, Organ Procurement Organization (Non-profit). Patricia A. Blissitt has received a salary from the American Association of Neuroscience Nurses as the Editor of the AANN Clinical Practice Guidelines. Sandralee A. Blosser, Jordan B. Bonomo, David M. Greer, Draga Jichici, Dea Mahanes, Evie G. Marcolini, Charles J. Miller, Kiranpal Sangha, and Susan Yeager declares no conflict of interest.

Supplementary material

12028_2015_137_MOESM1_ESM.docx (33 kb)
Supplementary material 1 (DOCX 33 kb)
12028_2015_137_MOESM2_ESM.docx (43 kb)
Supplementary material 2 (DOCX 43 kb)
12028_2015_137_MOESM3_ESM.docx (18 kb)
Supplementary material 3 (DOCX 18 kb)
12028_2015_137_MOESM4_ESM.docx (14 kb)
Supplementary material 4 (DOCX 18 kb)


  1. 1.
    Dixon TD, Malinoski DJ. Devastating brain injuries: assessment and management part I: overview of brain death. West J Emerg Med. 2009;10(1):11–7.PubMedCentralPubMedGoogle Scholar
  2. 2.
    Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380–2.PubMedCrossRefGoogle Scholar
  3. 3.
    Andrews JC, Schunemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol. 2013;66(7):726–35.PubMedCrossRefGoogle Scholar
  4. 4.
    Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol. 2013;66(7):719–25.PubMedCrossRefGoogle Scholar
  5. 5.
    Kotwica Z, Jakubowski JK. Head-injured adult patients with GCS of 3 on admission–who have a chance to survive? Acta Neurochir (Wien). 1995;133(1–2):56–9.CrossRefGoogle Scholar
  6. 6.
    Towfighi A, Tai W, Markovic D, Ovbiagele B. Sex-specific temporal trends in in-hospital mortality after stroke among middle-age individuals in the United States. Stroke. 2011;42(10):2740–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Ovbiagele B. Nationwide trends in in-hospital mortality among patients with stroke. Stroke. 2010;41(8):1748–54.PubMedCrossRefGoogle Scholar
  8. 8.
    Arabi YM, Haddad S, Tamim HM, Al-Dawood A, Al-Qahtani S, Ferayan A, et al. Mortality reduction after implementing a clinical practice guidelines-based management protocol for severe traumatic brain injury. J Crit Care. 2010;25(2):190–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Sturgeon JD, Folsom AR. Trends in hospitalization rate, hospital case fatality, and mortality rate of stroke by subtype in Minneapolis-St. Paul, 1980-2002. Neuroepidemiology. 2007;28(1):39–45.PubMedCrossRefGoogle Scholar
  10. 10.
    Andaluz N, Zuccarello M. Recent trends in the treatment of cerebral aneurysms: analysis of a nationwide inpatient database. J Neurosurg. 2008;108(6):1163–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Parry-Jones AR, Abid KA, Di Napoli M, Smith CJ, Vail A, Patel HC, et al. Accuracy and clinical usefulness of intracerebral hemorrhage grading scores: a direct comparison in a UK population. Stroke. 2013;44(7):1840–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Lu J, Marmarou A, Choi S, Maas A, Murray G, Steyerberg EW. Mortality from traumatic brain injury. Acta Neurochir Suppl. 2005;95:281–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Hemphill JC III, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004;35(5):1130–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Wang W, Lu J, Wang C, Wang Y, Li H, Zhao X. Prognostic value of ICH score and ICH-GS score in Chinese intracerebral hemorrhage patients: analysis from the China National Stroke Registry (CNSR). PLoS ONE. 2013;8(10):e77421.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980;6(1):1–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe A, et al. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol. 2011;10(7):618–25.PubMedCrossRefGoogle Scholar
  18. 18.
    Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg. 1988;68(6):985–6.Google Scholar
  19. 19.
    Gotoh O, Tamura A, Yasui N, Suzuki A, Hadeishi H, Sano K. Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery 1996;39(1):19–24; discussion-5.Google Scholar
  20. 20.
    Hirai S, Ono J, Yamaura A (1996) Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage. Neurosurgery 1996;39(3):441–446; discussion 6–7.Google Scholar
  21. 21.
    Lagares A, Gomez PA, Lobato RD, Alen JF, Alday R, Campollo J. Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage. Acta Neurochir (Wien). 2001;143(7):665–72.CrossRefGoogle Scholar
  22. 22.
    Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care. 2005;2(2):110–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Aulmann C, Steudl WI, Feldmann U. Validation of the prognostic accuracy of neurosurgical admission scales after rupture of cerebral aneurysms. Zentralbl Neurochir. 1998;59(3):171–80.PubMedGoogle Scholar
  24. 24.
    Morton V, Torgerson DJ. Effect of regression to the mean on decision making in health care. BMJ. 2003;326(7398):1083–4.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Massagli TL, Michaud LJ, Rivara FP. Association between injury indices and outcome after severe traumatic brain injury in children. Arch Phys Med Rehabil. 1996;77(2):125–32.PubMedCrossRefGoogle Scholar
  26. 26.
    Gatson JW, Warren V, Abdelfattah K, Wolf S, Hynan LS, Moore C, et al. Detection of beta-amyloid oligomers as a predictor of neurological outcome after brain injury. J Neurosurg. 2013;118(6):1336–42.PubMedCrossRefGoogle Scholar
  27. 27.
    Chabok SY, Moghadam AD, Saneei Z, Amlashi FG, Leili EK, Amiri ZM. Neuron-specific enolase and S100BB as outcome predictors in severe diffuse axonal injury. J Trauma Acute Care Surg. 2012;72(6):1654–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Settervall CH, de Sousa RM. Furbringer e Silva SC. In-hospital mortality and the Glasgow Coma Scale in the first 72 hours after traumatic brain injury. Rev Lat Am Enfermagem. 2011;19(6):1337–43.PubMedGoogle Scholar
  29. 29.
    Eriksson EA, Barletta JF, Figueroa BE, Bonnell BW, Sloffer CA, Vanderkolk WE, et al. The first 72 hours of brain tissue oxygenation predicts patient survival with traumatic brain injury. J Trauma Acute Care Surg. 2012;72(5):1345–9.PubMedGoogle Scholar
  30. 30.
    Kahraman S, Dutton RP, Hu P, Xiao Y, Aarabi B, Stein DM, et al. Automated measurement of “pressure times time dose” of intracranial hypertension best predicts outcome after severe traumatic brain injury. J Trauma. 2010;69(1):110–8.PubMedCrossRefGoogle Scholar
  31. 31.
    van Santbrink H, Schouten JW, Steyerberg EW, Avezaat CJ, Maas AI. Serial transcranial Doppler measurements in traumatic brain injury with special focus on the early posttraumatic period. Acta Neurochir (Wien). 2002;144(11):1141–9.CrossRefGoogle Scholar
  32. 32.
    Wolach B, Sazbon L, Gavrieli R, Broda A, Schlesinger M. Early immunological defects in comatose patients after acute brain injury. J Neurosurg. 2001;94(5):706–11.PubMedCrossRefGoogle Scholar
  33. 33.
    Togha M, Bakhtavar K. Factors associated with in-hospital mortality following intracerebral hemorrhage: a three-year study in Tehran. Iran BMC Neurol. 2004;4:9.PubMedCrossRefGoogle Scholar
  34. 34.
    Becker KJ, Baxter AB, Cohen WA, Bybee HM, Tirschwell DL, Newell DW, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766–72.PubMedCrossRefGoogle Scholar
  35. 35.
    O’Callahan JG, Fink C, Pitts LH, Luce JM. Withholding and withdrawing of life support from patients with severe head injury. Crit Care Med. 1995;23(9):1567–75.PubMedCrossRefGoogle Scholar
  36. 36.
    Tien HC, Cunha JR, Wu SN, Chughtai T, Tremblay LN, Brenneman FD, et al. Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma. 2006;60(2):274–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Brody A, Kashuk JL, Moore EE, Beauchamp K, Barnett C, Biffl WL, et al. (2010) Fatal gunshot wounds to the head: a critical appraisal of organ donation rates. Am J Surg. 2010;200(6):728–733; discussion 33.Google Scholar
  38. 38.
    Combes P, Fauvage B, Colonna M, Passagia JG, Chirossel JP, Jacquot C. Severe head injuries: an outcome prediction and survival analysis. Intensive Care Med. 1996;22(12):1391–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Murano T, Mohr AM, Lavery RF, Lynch C, Homnick AT, Livingston DH. Civilian craniocerebral gunshot wounds: an update in predicting outcomes. Am Surg. 2005;71(12):1009–14.PubMedGoogle Scholar
  40. 40.
    Bershad EM, Farhadi S, Suri MF, Feen ES, Hernandez OH, Selman WR, et al. Coagulopathy and inhospital deaths in patients with acute subdural hematoma. J Neurosurg. 2008;109(4):664–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Park SK, Chun HJ, Kim DW, Im TH, Hong HJ, Yi HJ. Acute physiology and chronic health evaluation II and simplified acute physiology score II in predicting hospital mortality of neurosurgical intensive care unit patients. J Korean Med Sci. 2009;24(3):420–6.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Labib N, Nouh T, Winocour S, Deckelbaum D, Banici L, Fata P, et al. Severely injured geriatric population: morbidity, mortality, and risk factors. J Trauma. 2011;71(6):1908–14.PubMedCrossRefGoogle Scholar
  43. 43.
    Cho DY, Wang YC. Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome. Intensive Care Med. 1997;23(1):77–84.PubMedCrossRefGoogle Scholar
  44. 44.
    Alvarez M, Nava JM, Rue M, Quintana S. Mortality prediction in head trauma patients: performance of Glasgow Coma Score and general severity systems. Crit Care Med. 1998;26(1):142–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Hyam JA, Welch CA, Harrison DA, Menon DK. Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care. 2006;10(Suppl 2):S2.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Dalgic A, Ergungor FM, Becan T, Elhan A, Okay O, Yuksel BC. The revised Acute Physiology and Chronic Health Evaluation System (APACHE II) is more effective than the Glasgow Coma Scale for prediction of mortality in head-injured patients with systemic trauma. Ulus Travma Acil Cerrahi Derg. 2009;15(5):453–8.PubMedGoogle Scholar
  47. 47.
    Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel. J Trauma. 2008;65(4):785–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Zafonte RD, Wood DL, Harrison-Felix CL, Millis SR, Valena NV. Severe penetrating head injury: a study of outcomes. Arch Phys Med Rehabil. 2001;82(3):306–10.PubMedCrossRefGoogle Scholar
  49. 49.
    Arboix A, Marti-Vilalta JL. Predictive clinical factors of very early in-hospital mortality in subarachnoid hemorrhage. Clin Neurol Neurosurg. 1999;101(2):100–5.PubMedCrossRefGoogle Scholar
  50. 50.
    Zhang G, Zhang JH, Qin X. Fever increased in-hospital mortality after subarachnoid hemorrhage. Acta Neurochir Suppl. 2011;110(Pt 1):239–43.Google Scholar
  51. 51.
    Arboix A, Massons J, Garcia-Eroles L, Oliveres M, Targa C. Diabetes is an independent risk factor for in-hospital mortality from acute spontaneous intracerebral hemorrhage. Diabetes Care. 2000;23(10):1527–32.PubMedCrossRefGoogle Scholar
  52. 52.
    Fanshawe M, Venkatesh B, Boots RJ. Outcome of stroke patients admitted to intensive care: experience from an Australian teaching hospital. Anaesth Intensive Care. 2002;30(5):628–32.PubMedGoogle Scholar
  53. 53.
    Cucchiara BL, Kasner SE, Wolk DA, Lyden PD, Knappertz VA, Ashwood T, et al. Early impairment in consciousness predicts mortality after hemispheric ischemic stroke. Crit Care Med. 2004;32(1):241–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, et al. Risk score for in-hospital ischemic stroke mortality derived and validated within the Get With the Guidelines-Stroke Program. Circulation. 2010;122(15):1496–504.PubMedCrossRefGoogle Scholar
  55. 55.
    Savadi-Oskouei D, Sadeghi-Bazargani H, Hashemilar M, DeAngelis T. Symptomatologic versus neuroimaging predictors of in-hospital survival after intracerebral haemorrhage. Pak J Biol Sci. 2010;13(9):443–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Rordorf G, Koroshetz W, Efird JT, Cramer SC. Predictors of mortality in stroke patients admitted to an intensive care unit. Crit Care Med. 2000;28(5):1301–5.PubMedCrossRefGoogle Scholar
  57. 57.
    Bond AE, Draeger CR, Mandleco B, Donnelly M. Needs of family members of patients with severe traumatic brain injury. Implications for evidence-based practice. Crit Care Nurse. 2003;23(4):63–72.PubMedGoogle Scholar
  58. 58.
    Frid I, Bergbom I, Haljamae H. No going back: narratives by close relatives of the braindead patient. Intensive Crit Care Nurs. 2001;17(5):263–78.PubMedCrossRefGoogle Scholar
  59. 59.
    Keenan A, Joseph L. The needs of family members of severe traumatic brain injured patients during critical and acute care: a qualitative study. Can J Neurosci Nurs. 2010;32(3):25–35.PubMedGoogle Scholar
  60. 60.
    Lam P, Beaulieu M. Experiences of families in the neurological ICU: a “bedside phenomenon”. J Neurosci Nurs. 2004;36(3):142–146, 51–55.Google Scholar
  61. 61.
    Payne S, Burton C, Addington-Hall J, Jones A. End-of-life issues in acute stroke care: a qualitative study of the experiences and preferences of patients and families. Palliat Med. 2010;24(2):146–53.PubMedCrossRefGoogle Scholar
  62. 62.
    Mathis M. Personal needs of family members of critically ill patients with and without acute brain injury. J Neurosurg Nurs. 1984;16(1):36–44.PubMedCrossRefGoogle Scholar
  63. 63.
    Prachar TL, Mahanes D, Arceneaux A, Moss BL, Jones S, Conaway M, et al. Recognizing the needs of family members of neuroscience patients in an intensive care setting. J Neurosci Nurs. 2010;42(5):274–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Tin MK, French P, Leung KK. The needs of the family of critically ill neurosurgical patients: a comparison of nurses’ and family members’ perceptions. J Neurosci Nurs. 1999;31(6):348–56.PubMedCrossRefGoogle Scholar
  65. 65.
    Forrester DA, Murphy PA, Price DM, Monaghan JF. Critical care family needs: nurse-family member confederate pairs. Heart Lung. 1990;19(6):655–61.PubMedGoogle Scholar
  66. 66.
    Price DM, Forrester DA, Murphy PA, Monaghan JF. Critical care family needs in an urban teaching medical center. Heart Lung. 1991;20(2):183–8.PubMedGoogle Scholar
  67. 67.
    Engli M, Kirsivali-Farmer K. Needs of family members of critically ill patients with and without acute brain injury. J Neurosci Nurs. 1993;25(2):78–85.PubMedCrossRefGoogle Scholar
  68. 68.
    Duff D. Family concerns and responses following a severe traumatic brain injury: a grounded theory study. Axone. 2002;24(2):14–22.PubMedGoogle Scholar
  69. 69.
    Merritt KL, Evans RL. Family satisfaction with medical care after traumatic brain injury. Psychol Rep. 1990;67(1):129–30.PubMedCrossRefGoogle Scholar
  70. 70.
    Lefebvre H, Pelchat D, Swaine B, Gelinas I, Levert MJ. The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum. Brain Inj. 2005;19(8):585–97.PubMedCrossRefGoogle Scholar
  71. 71.
    Long B, Clark L, Cook P. Surrogate decision making for patients with severe traumatic brain injury. J Trauma Nurs. 2011;18(4):204–12.PubMedCrossRefGoogle Scholar
  72. 72.
    Wellwood I, Dennis M, Warlow C. Patients’ and carers’ satisfaction with acute stroke management. Age Ageing. 1995;24(6):519–24.PubMedCrossRefGoogle Scholar
  73. 73.
    Lefebvre H, Levert MJ. Breaking the news of traumatic brain injury and incapacities. Brain Inj. 2006;20(7):711–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Kesselring A, Kainz M, Kiss A. Traumatic memories of relatives regarding brain death, request for organ donation and interactions with professionals in the ICU. Am J Transpl. 2007;7(1):211–7.CrossRefGoogle Scholar
  75. 75.
    Schats R, Brilstra EH, Rinkel GJ, Algra A, Van Gijn J. Informed consent in trials for neurological emergencies: the example of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. 2003;74(7):988–91.PubMedCentralPubMedCrossRefGoogle Scholar
  76. 76.
    Fox S, Jeffrey J. The role of the nurse with families of patients in ICU: the nurses’ perspective. Can J Cardiovasc Nurs = Journal canadien en soins infirmiers cardio-vasculaires. 1997;8(1):17–23.Google Scholar
  77. 77.
    Mirr MP. Factors affecting decisions made by family members of patients with severe head injury. Heart Lung. 1991;20(3):228–35.PubMedGoogle Scholar
  78. 78.
    White DB, Cua SM, Walk R, Pollice L, Weissfeld L, Hong S, et al. Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness. Am J Crit Care. 2012;21(6):396–409.PubMedCentralPubMedCrossRefGoogle Scholar
  79. 79.
    Bernstein LP. Family-centered care of the critically III neurologic patient. Crit Care Nurs Clinics North Am. 1990;2(1):41–50.Google Scholar
  80. 80.
    Mirr MP. Decisions made by family members of patients with severe head injury. AACN Clin Issues Crit Care Nurs. 1991;2(2):242–51.PubMedGoogle Scholar
  81. 81.
    Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma. 2007;24(Suppl 1):S7–13.PubMedGoogle Scholar
  82. 82.
    Toms SA. Outcome predictors in the early withdrawal of life support: issues of justice and allocation for the severely brain injured. J Clin Ethics. 1993;4(3):206–11.PubMedGoogle Scholar
  83. 83.
    Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111(4):683–7.PubMedCentralPubMedCrossRefGoogle Scholar
  84. 84.
    Council on Ethical and Judicial Affairs AMA. Decisions near the end of life. JAMA. 1992;267(16):2229–33.CrossRefGoogle Scholar
  85. 85.
    Cruzan v. Director, Missouri Dept. of Health: Hearing before the United States Reports, United States Reports, 497 Sess. (1990, 1990).Google Scholar
  86. 86.
    Gillett GR, Honeybul S, Ho KM, Lind CR. Neurotrauma and the RUB: where tragedy meets ethics and science. J Med Ethics. 2010;36(12):727–30.PubMedCrossRefGoogle Scholar
  87. 87.
    Sander SL, Miller BK. Public knowledge and attitudes regarding organ and tissue donation: an analysis of the northwest Ohio community. Patient Educ Couns. 2005;58(2):154–63.PubMedCrossRefGoogle Scholar
  88. 88.
    Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309(6948):184–8.PubMedCentralPubMedCrossRefGoogle Scholar
  89. 89.
    Baumann A, Claudot F, Audibert G, Mertes PM, Puybasset L. The ethical and legal aspects of palliative sedation in severely brain-injured patients: a French perspective. Philos Ethics Hum Med. 2011;6:4.CrossRefGoogle Scholar
  90. 90.
    Dyer C. Appeal Court supports doctors’ decision not to treat. BMJ. 1992;304(6841):1527–8.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Michael J. Souter
    • 1
    Email author
  • Patricia A. Blissitt
    • 2
    • 3
  • Sandralee Blosser
    • 4
    • 5
  • Jordan Bonomo
    • 6
    • 7
  • David Greer
    • 8
  • Draga Jichici
    • 9
  • Dea Mahanes
    • 10
  • Evie G. Marcolini
    • 11
  • Charles Miller
    • 12
  • Kiranpal Sangha
    • 13
  • Susan Yeager
    • 14
  1. 1.Departments of Anesthesiology & Pain Medicine, and Neurological surgery, Harborview Medical CenterUniversity of WashingtonSeattleUSA
  2. 2.Harborview Medical CenterUniversity of Washington School of NursingSeattleUSA
  3. 3.Swedish Medical CenterSeattleUSA
  4. 4.Pittsburgh Critical Care AssociatesPittsburghUSA
  5. 5.Penn State Hershey Medical CenterHersheyUSA
  6. 6.Department of Emergency Medicine, Division of Critical CareUniversity of Cincinnati College of MedicineCincinnatiUSA
  7. 7.Department of Neurosurgery, Division of Neurocritical CareUniversity of Cincinnati College of MedicineCincinnatiUSA
  8. 8.Departments of Neurology and NeurosurgeryYale University School of MedicineNew HavenUSA
  9. 9.Department of Neurology and Critical Care MedicineMcMaster UniversityHamiltonUSA
  10. 10.University of Virginia Health SystemCharlottesvilleUSA
  11. 11.Departments of Emergency Medicine and Neurology, Divisions of Neurocritical Care and Emergency Neurology and Surgical Critical CareYale University School of MedicineNew HavenUSA
  12. 12.Sanford University South Dakota School of MedicineSioux FallsUSA
  13. 13.University of Cincinnati Medical Center and University of Cincinnati College of PharmacyCincinnatiUSA
  14. 14.The Ohio State University Wexner Medical CenterColumbusUSA

Personalised recommendations