The window of opportunity: decision theory and the timing of prognostic tests for newborn infants.
In many forms of severe acute brain injury there is an early phase when prognosis is uncertain, followed later by physiological recovery and the possibility of more certain predictions of future impairment. There may be a window of opportunity for withdrawal of life support early, but if decisions are delayed there is the risk that the patient will survive with severe impairment. In this paper I focus on the example of neonatal encephalopathy and the question of the timing of prognostic tests and decisions to continue or to withdraw life-sustaining treatment. Should testing be performed early or later; and how should parents decide what to do given the conflicting values at stake? I apply decision theory to the problem, using sensitivity analysis to assess how different features of the tests or different values would affect a decision to perform early or late prognostic testing. I draw some general conclusions from this model for decisions about the timing of testing in neonatal encephalopathy. Finally I consider possible solutions to the problem posed by the window of opportunity. Decision theory highlights the costs of uncertainty. This may prompt further research into improving prognostic tests. But it may also prompt us to reconsider our current attitudes towards the palliative care of newborn infants predicted to be severely impaired.
The Ethox Centre, Department of Public Health and Primary Health Care, University of Oxford, Oxford, UK. dominic.wilkinson@ethox.ox.ac.uk
Dominic
D
Wilkinson
D001930:Brain Injuries / Q000150:complications / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D003220:Conflict, Psychological; D016638:Critical Illness; D003657:Decision Making / Q000941:ethics*; D003662:Decision Theory; D003663:Decision Trees; D042241:Early Diagnosis; D026690:Ethics, Clinical; D006801:Humans; D002534:Hypoxia, Brain / Q000150:complications*; D007231:Infant, Newborn; D015997:Neonatal Screening / Q000941:ethics*; D011237:Predictive Value of Tests; D011379:Prognosis; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors; D035501:Uncertainty; D028761:Withholding Treatment / Q000941:ethics*