Skip to main content

Table 4 Proposal of a clinical approach to handling prognostic information in patients with severe ICH and “full code” status

From: Prognostication after intracerebral hemorrhage: a review

First approach to the patient Clarify code status. Be aware of your own biases. Especially in patients with large ICH volumes and/or IVH extension and/or hydrocephalus do not reflexively, consciously or subconsciously, provide sub-maximal care. Unless patients are at immediate risk of dying or fulfill criteria for brain death, provide maximal therapy, at least until contact with family is established and/or direct access to patient’s living will.
First family communication Establish a relationship of trust and try to speak with close family members in person rather than on the phone if possible. Inquire whether a documented living will exists. Provide objective information. Avoid choice of words or implicit communication elements that suggest a likely clinical outcome (it is reasonable however to say that the disease is “severe” or “potentially life-threatening” if that is the case). Assess the family’s overall understanding of the situation, explain the disease, leave room for questions.
Score prognostication Calculate the likelihood of unfavorable outcome using a recently validated prediction score. Be aware of the shortcomings of current prognostication tools, especially the lack of incorporation of worsening or improvement of the patient over time. Never make a definitive recommendation/decision solely based on the score results.
Second family communication Use the score information to give the family a sense how patients with a similar disease severity have done in the past. Avoid confronting patients/families with numbers. In rare cases, if the educational level of family allows it, explain biases and shortcomings of our current prediction tools. Explain that aggressive therapy may make a relative outcome difference even in situations where moderate to severe disability is very likely.