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Recovery Over 6 Months of Medical Decision-Making Capacity After Traumatic Brain Injury

Published:August 22, 2014DOI:https://doi.org/10.1016/j.apmr.2014.07.413

      Highlights

      • Many patients with traumatic brain injury (TBI) have impaired medical decision-making capacity (MDC) 1 month postinjury.
      • Partial or full recovery of MDC occurs in many patients over the first 6 months.
      • MDC outcomes depend on injury severity.
      • 20% of mild cases and 35% of complicated mild cases have impaired MDC 6 months after TBI.
      • 50% of moderate to severe cases have impaired MDC 6 months after TBI.

      Abstract

      Objective

      To investigate recovery of medical decision-making capacity (MDC) over 6 months in persons with traumatic brain injury (TBI) stratified by injury severity.

      Design

      Longitudinal study comparing controls and patients with TBI 1 month after injury (t1) and 6 months after injury (t2).

      Setting

      Inpatient TBI rehabilitation unit and outpatient neurology department.

      Participants

      Participants (N=151) consisted of control subjects (n=60) and patients with TBI (n=91) stratified by injury severity: mild TBI (mTBI; n=27), complicated mild TBI (cmTBI; n=20), and moderate/severe TBI (msevTBI; n=44).

      Interventions

      Not applicable.

      Main Outcome Measures

      We used the Capacity to Consent to Treatment Instrument to evaluate MDC performance on 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, and understanding). We also assigned capacity impairment ratings on the consent standards to each participant with TBI using cut scores referenced to control performance.

      Results

      Control performance was stable across time on the consent standards. Patients with mTBI and cmTBI performed below controls on the understanding standard at t1 but not t2. Patients with msevTBI performed below controls on appreciation, reasoning, and understanding at t1, and on appreciation and understanding at t2, but showed substantial improvement over time.

      Conclusions

      Regardless of injury severity, all groups with TBI demonstrated baseline impairment of MDC with subsequent partial or full recovery of MDC over a 6-month period. However, a sizeable proportion of individual patients with TBI in each group continued to demonstrate capacity compromise at 6 months postinjury. Clinically, this finding suggests that individuals with TBI, regardless of injury severity, need continued monitoring regarding MDC for at least 6 months after injury.

      Keywords

      List of abbreviations:

      ANOVA (analysis of variance), CCTI (Capacity to Consent to Treatment Instrument), cmTBI (complicated mild TBI), CT (computed tomography), GCS (Glasgow Coma Scale), MDC (medical decision-making capacity), msevTBI (moderate/severe TBI), mTBI (mild TBI), PTA (posttraumatic amnesia), TBI (traumatic brain injury)
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