title: Surgical decision making for the elderly patients in severe head injuries.
abstract: OBJECTIVE
  Age is a strong predictor of mortality in traumatic brain injuries. A surgical decision making is difficult especially for the elderly patients with severe head injuries. We studied so-called 'withholding a life-saving surgery' over a two year period at a university hospital.
  
  
  METHODS
  We collected data from 227 elderly patients. In 35 patients with Glasgow Coma Score 3-8, 28 patients had lesions that required operation. A life-saving surgery was withheld in 15 patients either by doctors and/or the families (Group A). Surgery was performed in 13 patients (Group B). We retrospectively examined the medical records and radiological findings of these 28 patients. We calculated the predicted probability of 6 month mortality (IPM) and 6 month unfavorable outcome (IPU) to compare the result of decision by the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) calculator.
  
  
  RESULTS
  Types of the mass lesion did not affect on the surgical decision making. None of the motor score 1 underwent surgery, while all patients with reactive pupils underwent surgery. Causes of injury or episodes of hypoxia/hypotension might have affected on the decision making, however, their role was not distinct. All patients in the group A died. In the group B, the outcome was unfavorable in 11 of 13 patients. Patients with high IPM or IPU were more common in group A than group B. Wrong decisions brought futile cares.
  
  
  CONCLUSIONS
  Ethical training and developing decision-making skills are necessary including shared decision making.
authors.affiliation: Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Kyeong-Seok
authors.initials: KS
authors.lastname: Lee
authors.affiliation: Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Jae-Jun
authors.initials: JJ
authors.lastname: Shim
authors.affiliation: Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Seok-Man
authors.initials: SM
authors.lastname: Yoon
authors.affiliation: Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Jae-Sang
authors.initials: JS
authors.lastname: Oh
authors.affiliation: Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Hack-Gun
authors.initials: HG
authors.lastname: Bae
authors.affiliation: Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea.
authors.forename: Jae-Won
authors.initials: JW
authors.lastname: Doh
keywords: Craniocerebral trauma; Decision making; Patient participation; Prognosis