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Invited Commentary
January 2018

Treatment Intensity After Traumatic Brain Injury: More Is Not Better

Author Affiliations
  • 1Berkeley-University of California, San Francisco Joint Medical Program, University of California, Berkeley
  • 2Departments of Surgery and Medicine, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco
JAMA Surg. 2018;153(1):51. doi:10.1001/jamasurg.2017.3139

Optimal care when the end of life is near is based on in the principle of patient autonomy. Surgeons, however, are often hesitant to limit life-sustaining interventions even if patients prefer less aggressive care at the end of life.1,2 The challenges for incorporating patient preferences and values in the context of high-risk surgery may be explained in several ways. Schwarze et al2 described the concept of surgical “buy-in,” in which surgeons performing high-risk surgery expect their patients to agree to certain postoperative care in an unspoken contractual agreement made during the preoperative conversation. The expectations of buy-in are grounded in surgeons’ strong sense of responsibility for surgical outcomes and the pervasive notion that a patient who dies represents a treatment failure. Second, the pressure of the 30-day mortality metric may create an incentive to encourage aggressive life-sustaining treatments.3

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