Outcome and ethics in severe brain damage

The patient with severe brain damage represents a considerable ethical challenge for the medical team due to uncertainties in diagnosis and prognosis, the younger age of many of these patients, and the frequent acute nature of the disease, which allows little time for discussion of end-of-life issues with the patient. Surrogates are often relied on to fill in the gaps and provide their, not always reliable, interpretation of how they feel the patient would want to have been treated. The debate regarding the withdrawing/withholding of life-sustaining treatment is discussed but may not apply to many patients with severe brain damage who do not usually require invasive life support. However, withdrawal of artificial feeding and hydration is very relevant to such patients and is highly controversial. These issues are highly emotive and subjective, and individuals' views will depend on many factors including cultural background and religion. There are relatively few published data regarding ethical issues in the severely brain damaged patient and open discussion of the multiple facets of this difficult area must be encouraged.