LAUSR

Decompressive craniectomy (DC) has during the past decade become a treatment option for patients with life-threatening, severe, increased intracranial pressure unresponsive to nonsurgical treatments. The evidence for efficacy of DC is especially high when increased intracranial pressure is caused by malignant media infarction (MMI) [1, 2]. In this setting, DC has been proved to significantly reduce mortality. The lifesaving quality of DC might be justification enough for some to implement the procedure in routine use, but for others it needs to lead to a minimum quality of life that makes life worth living. This reflection is extremely relevant in this context because DC in MMI is very likely to save the patient’s life, but it will not reverse the severe neurological deficits induced by the stroke itself. In some patients the procedure will even induce more severe neurological deficits. The modified Rankin scale (mRS) has become the primary outcome tool in most studies of DC. When dichotomising the seven-point mRS into favourable and unfavourable outcomes, it was planned to set the divider between mRS3 (moderate disability—requires some help, but able to walk unassisted) and mRS4 (moderately severe disability—unable to attend to own bodily needs without assistance, and unable to walk unassisted). However, the divider was shifted and instead set between mRS4 and mRS5 (severe disability—requires constant nursing care and attention, bedridden, incontinent) as this and not the planned dichotomisation demonstrated a significant effect of DC in MMI [1, 2]. Setting the cut-off mark for what life is worth living is at the centre of the article by Magnus Olivecrona from Sweden and Stephen Honeybul from Australia in the current issue of Acta Neurochirurgica [3]. They investigated what neurological outcome after DC for MMI healthcare professionals in Sweden find acceptable. The study is at the same time a replication of a similar study performed in Australia and offers a peek at potential cultural differences between Sweden and Australia [4]. These studies address the eternal question: BYes we can, but should we?^. In the current study the authors asked healthcare professionals to complete a questionnaire, where they were asked to imagine that they had just had an MMI and a DC was considered. What type of neurological deficits would they find acceptable to live with faced with the choice of accepting or declining the procedure. The participants were doctors and nurses working in intensive care, neurology or cardiology. They all received information similar to a very elaborate informed consent for the procedure, including the opportunity to ask questions, and they were introduced to a Swedish translation of the mRS [3]. In this study only 4% of the participants (24 of 609) would accept a mRS5 as outcome and 30% would accept mRS4 as outcome. When comparing with the HAMLET study [2] 75% of the patients would end up in a state that only 30% found acceptable and almost 20% would end up in a state that only 4% found acceptable. In this editorial, we analyse the ethical aspects of DC for malignant media infarction, primarily based on the four principles often used to guide choices within the sphere of medical ethics, namely: beneficence, non-maleficence, autonomy and justice [5]. * Jannick Brennum [email protected]