Livin’ on a Prayer: The Intersection of Prognostication, Code Status, and Palliative Care

Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of life-sustaining treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate, variable, and overly pessimistic. Overly pessimistic prognostication can lead to therapeutic nihilism and a self-fulfilling prophecy. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do-Not-Resuscitate orders has been shown to be associated with increased mortality. Similarly, palliative care, despite its many positive benefits, may unintentionally influence perceptions of prognosis, both by healthcare professionals and families, potentially contributing to therapeutic nihilism. Because withdrawal of life-sustaining treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication, code status, and palliative care in patients with severe brain injury is needed.