NU657 Unit 8 Family Meeting Summary, Severe TBI Example

Whose Decision Stands: A Family Meeting Summary on Tracheostomy and a Feeding Tube Eleven Days After Severe Traumatic Brain Injury in a 63-Year-Old Man

[Student Name]

Purdue University Global

NU657: AGACNP Critical Care Management Clinical

Unit 8 Family Meeting Summary

[Instructor Name]

[Date]

The patient and family are composite; names, dates and values are bracketed.

Meeting Details

Date and time: [day 11], [15:30 to 16:40], family conference room, neurotrauma intensive care unit.

Participants and roles:

1. Mr. [D. K.], the patient's partner of [22] years, named as health care agent in a durable power of attorney signed in [2019], scanned into the chart under advance directives.

2. Ms. [L.] and Ms. [T.], the patient's adult daughters.

3. Dr. [O.], neurocritical care attending, who led the meeting.

4. [R.], bedside nurse for the last [four] days.

5. [S.], social worker.

6. Chaplain [E.], at the partner's request.

7. The author, acute care nurse practitioner student, note writer.

Legal authority: the durable power of attorney names Mr. [D. K.] as agent. It takes precedence over the state's default order of surrogates, which would otherwise place the adult children first, since the couple are not married. Both daughters were told this at the start of the meeting and said they understood.

Capacity: the patient cannot take part. He opens his eyes to voice but does not track or follow commands, Glasgow Coma Scale [8] with a tracheal tube.

Clinical Update, in the Words Used at the Table

Dr. [O.] said: "Mr. [P.]'s brain was badly injured when he fell. The swelling has come down and he is breathing more on his own, so he will very likely survive this. What we cannot promise is how much he will recover. From what we see after eleven days, he may not walk or talk again, and he will probably need help with all of his daily care for a long time, possibly for the rest of his life. Some people improve over months, and we cannot rule that out."

He added that the breathing tube cannot stay in much longer, so the family needs to choose between a tracheostomy and feeding tube with a move to a long-term acute care hospital, or a shift to comfort-focused care with removal of the breathing tube.

The attending did not use a numerical prognosis at the table. In his note he recorded that admission-based models for traumatic brain injury predict outcome for groups rather than individuals (Steyerberg et al., 2008), and that decisions to withdraw treatment early after severe brain injury vary widely between centers and may themselves influence mortality (Turgeon et al., 2011), which is one reason the team waited until day [11] to hold this meeting.

What Each Participant Said About His Wishes

Mr. [D. K.] said that after a friend's stroke [five] years ago, the patient told him he "would put up with a long, hard recovery if there was a real chance of getting back to something." He said the patient never talked about a tube in his neck or in his stomach specifically.

Ms. [L.] said that her father refused to move his own father into a nursing home and cared for him at home until he died, and that he "would hate being cared for by strangers." She said she thinks he would not want to live without being able to speak.

Ms. [T.] said she agreed with her sister about the nursing home, but that her father was "a fighter" and might want time to see if he improves.

The bedside nurse reported that over the last [two] days he has turned his head toward his partner's voice more than toward others, which she described without drawing a conclusion from it.

The chaplain and social worker did not offer views on his wishes; the social worker explained what a long-term acute care hospital provides and what the likely next steps after it would be.

Options Discussed

1. Tracheostomy and gastrostomy, transfer to a long-term acute care hospital, and a planned review of his progress with the family at [three] months, with a clear agreement to revisit the goals if he has not improved.

2. Comfort-focused care: removal of the breathing tube in the intensive care unit with medications for comfort, no feeding tube, and hospice involvement.

Both options were presented as reasonable. The team explained that a time-limited trial, option 1 with a set review, is a way to honor both his willingness to recover and his dislike of long-term dependence. The shared decision-making statement of the critical care societies describes this kind of approach, where the team offers a recommendation informed by the patient's values while the surrogate makes the decision (Kon et al., 2016).

Decision

Mr. D. K., as the agent named by the patient, chose a tracheostomy and feeding tube with a three-month review, grounding his choice in the patient's words about a long recovery with a real chance. Ms. [L.] said she did not fully agree but would support the decision because it was her father's partner's to make and because there would be a review. Ms. [T.] agreed with the decision. The attending supported it as consistent with the patient's stated values.

Plan and Follow-Up

1. Tracheostomy and percutaneous gastrostomy scheduled for [day 13], consent from Mr. [D. K.] as agent.

2. Social work to begin referrals to [two] long-term acute care hospitals tomorrow and to share the three-month review plan with the accepting facility.

3. The three-month review will include a repeat neurologic examination and a meeting with the partner and both daughters; the question of continuing or changing the goals will be revisited then.

4. Palliative care consultation for ongoing support of the family, including Ms. [L.], who asked to talk further.

5. Chaplaincy to continue visits at the partner's request.

References

Kon, A. A., Davidson, J. E., Morrison, W., Danis, M., & White, D. B. (2016). Shared decision making in ICUs: An American College of Critical Care Medicine and American Thoracic Society policy statement. Critical Care Medicine, 44(1), 188-201. https://doi.org/10.1097/CCM.0000000000001396

Steyerberg, E. W., Mushkudiani, N., Perel, P., Butcher, I., Lu, J., McHugh, G. S., Murray, G. D., Marmarou, A., Roberts, I., Habbema, J. D. F., & Maas, A. I. R. (2008). Predicting outcome after traumatic brain injury: Development and international validation of prognostic scores based on admission characteristics. PLoS Medicine, 5(8), Article e165. https://doi.org/10.1371/journal.pmed.0050165

Turgeon, A. F., Lauzier, F., Simard, J.-F., Scales, D. C., Burns, K. E. A., Moore, L., Zygun, D. A., Bernard, F., Meade, M. O., Dung, T. C., Ratnapalan, M., Todd, S., Harlock, J., & Fergusson, D. A. (2011). Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: A Canadian multicentre cohort study. Canadian Medical Association Journal, 183(14), 1581-1588. https://doi.org/10.1503/cmaj.101786